What Is Motivational Interviewing?
Motivational interviewing (MI) is a therapeutic approach used to explore and resolve ambivalence about behavior change. There is a strong evidence base to suggest that it reduces substance use problems and a growing evidence base for other problems. MI is an empathic therapeutic approach that explores and resolves lingering ambivalence about change. The clinician intentionally pursues the resolution of ambivalence and initiation of positive change as central goals, while maintaining focus on the client’s concerns, perceptions, hopes, and goals rather than on those of the provider. MI communications are primarily reflections, open questions, and affirmations, avoiding an expert stance implied by a clinician-centered therapeutic agenda and heavy use of closed questions, information-provision, and advice. Thus while focusing on and eliciting the client’s perceptions, the MI clinician explores areas of unresolved ambivalence and guides the client to resolve them to improve the client’s life.
MI was first described as a way to work with people having problems with drinking. From an MI perspective, addiction is viewed as “fundamentally a problem of motivation” (p. 134). Cravings, urges, temptations, expectancies, problem recognition, perceived social norms and contingencies, perceived importance of and ability to change, and other addiction-related constructs all have significant motivational components. The development of addiction involves a process of diminishing volitional control of the addictive behaviors involved. As addiction intensifies, capacity for self-regulation diminishes—never below retrievable levels, but enough that it becomes ever more difficult for the person to consistently behave in consciously chosen ways.
Along the pathway to addiction, people often have mixed feelings and thoughts about their drug and alcohol use. Although they may perceive some negative consequences of drinking or using, they also enjoy positive experiences such as intoxication, disinhibition, socialization, and pleasure. Alternatively, they may strongly want to change but feel unable. Whether mild or more extreme, these ambivalence conflicts often remain unresolved for years before significant changes are made. Understanding and resolving this ambivalence is a central goal of MI and is accomplished through elicitation rather than persuasion. Clinicians elicit the client’s ideas and feelings about the current behavior, how the behavior fits in with their values, and what changes they might make to move toward a better future. The provider elicits the client’s own motives and rationale for possible change, referred to in MI research as “change talk.” In essence, MI is focused more on the whether and why to change than on the how .
Because MI is a therapy with a humanistic core, the basis of its conceptualization of addiction is that a person’s process of natural growth and development is being blocked and that the person has become stuck. The process of helping the person is not one of curing a disorder or altering a learning history, but of enabling growth and development. Like releasing a river that has become dammed, the process of helping may be as simple as opening up a channel to allow the flow to begin again; the river itself often takes care of the rest. Unresolved ambivalence makes up the core of the dam, slowing the river’s momentum. Removing the barrier of unresolved ambivalence allows for a return to the natural flow toward health and well-being.
The counseling style used in MI is “quiet and eliciting” and the “therapeutic relationship is more like a partnership….than expert/recipient roles.” The spirit of MI may be more important than techniques, per se. The MI spirit is one of collaboration between two experts, the client having intimate knowledge of the self and the provider having skill in guiding conversations so that clarity of purpose emerges along with an increased sense of empowerment to take action. The spirit of MI is based on a respect and admiration for the client’s autonomy, which is manifested as explicit support for the client’s ability and authority to consider options, make choices, and take action. Finally, the spirit of MI is evocative. Clinicians explore and reflect the client’s perceptions in such a way that a new understanding or commitment is evoked through the conversation. The provider explores the client’s own concerns and elicits from the client a desire for change and a working plan to make it happen in a way that the client feels optimistic about it.
Although the clinician has a goal of facilitating the exploration and resolution of ambivalence, and may have ideas about promising directions, the provider is not attached to any single, specific outcome or pathway to get there. By remaining focused on the client’s concerns and ideas about change, clinicians can assess the client’s current readiness to change and tailor the strategies they use.
The relational stance in MI is one of respect and collaboration. 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. Complementing the client’s effort, the provider offers reflections, questions, and summaries, while affirming the client’s work. Clinicians using the MI approach tend to ask rather than tell, and to listen rather than advise. MI clinicians show curiosity rather than content expertise, even when they have substantial expertise in the area of the client’s concern. It is more important that the MI clinician focus on developing an understanding of the client’s perspective rather than providing information, education, or persuasion, all of which may provoke resistance or reluctance.
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. These fundamental techniques are used to build rapport and gain understanding of a client’s issues, to mend rifts in the treatment relationship, to redirect clients to more useful areas of consideration, and to solidify commitment to change in an established relationship where therapeutic alliance is strongly present.
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. In MI, the engaging process involves two essential elements: (1) engaging them in a conversation that facilitates the process of self-exploration and disclosure; and (2) engaging them in a trusting, collaborative relationship focused on developing a shared understanding of the client’s inner life as it relates to making positive changes. 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. With these questions answered or at least made less prominent in clients’ minds, they can more honestly and carefully consider their current situation and their options to move forward toward a better future.
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. Client engagement is also threatened when clinicians take an expert stance, in which the client’s role is to simply report on problems, answer questions, provide information, and wait for the professional to sort out, solve, and render advice on how best to resolve the problems at hand. 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. When using MI, it may be best to delay any intensive assessment of clinical problems until after an initial conversation, and even then to sandwich the assessment between two brief MI-style conversations focusing more on the client’s concerns, interests, and hopes.
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. In these moments, returning to a focus on engaging can help reestablish the therapeutic bond and diminish whatever internal experience is threatening the client’s sense of well-being and preventing them from engaging in an open, productive discussion.
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. “Quitting use of all psychoactive substances” may be clearer and more attainable than “quitting smoking, reducing drinking, and moderating caffeine intake.”
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. This involves first setting the stage to have the conversation, then developing a list of possible focus areas, then focusing on topics that could use fleshing out to establish a better understanding, then returning to a birds-eye view to examine how the topics fit together and to develop a plan for the journey ahead, deciding which topics/challenges to address first, second, at a later time, and so on. 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.
Finally, when practitioners and clients have different ideas about what to focus on or different opinions about which direction the client should pursue or how to go about it, the MI model cautions practitioners to monitor their “righting reflex,” or their desires to fix things that are not going well in clients’ lives. 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. Or a client may want to talk about apparent unfairness of cannabis laws or injustices in the criminal justice system, while the provider may want to focus on connections between the client’s cannabis use and his or her inconsistent work history. 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.g., the circumstances of the arrest as well as other circumstances in which no arrest occurred), finding subtle connections between the areas and then working forward by inviting the client to explore things in such a way that both focus areas become integrated into the discussion.
Regardless of which situation fits a specific client, the goal is to join them where they are and work together toward next steps.
The third process is evoking, specifically evoking clients’ motivation to change. 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. Thus MI typically deemphasizes provision of general information or specific advice and emphasizes instead the process of eliciting clients’ perspective and their own autonomous motivations to change. It does so by focusing attention on clients’ values, preferences, hopes, and desires. 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., self-determination theory; Markland et al. ).
The process of evoking is the core of motivational interviewing. Key tasks include eliciting and responding to change talk in order to build momentum toward making positive change, accepting and responding to sustain talk in ways that prevent either defensiveness or inertia, enhancing hope for success, and heightening clients’ awareness of any discrepancies between their current choices and their goals or values in order to encourage greater convergence. Evidence (reviewed later) is accumulating that the counselor’s therapeutic style and focus on eliciting and reinforcing change talk do in fact increase change talk, commitment to change, and subsequent action.
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 .
A number of simple strategies can be used to increase clients’ sense of the importance of making changes. First, practitioners can explore the good and less good things about a current problematic habit like substance use. While exploring the status quo side of ambivalence (good things about staying the same, bad things about changing) may not be necessary and may be contraindicated for some clients, for others, particularly those who are defensive about their use, it can increase practitioners’ understanding of client perspectives, help clients open up and bond with the practitioner, allow clients to vent so that they can then more productively consider change, and help identify potential obstacles that may arise later on in change attempts. 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
How would you like things to be different? (desire)
What are some ways things could be better if you decided to quit drinking? (reasons)
What would you say is the most important thing you could do now to prevent things from getting worse in the future? (need)
Practitioners can also do importance scaling, in which they ask the client to rate the importance of making a change on a scale from 0 to 10, and then follow-up by asking, “What makes your rating X instead of 0 (or another lower number)?” thus eliciting change talk (the client saying out loud what is important about making a change). 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. Envisioning a better future can also increase clients’ sense of importance of making a change. 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. Once again, practitioners can use evocative questions to elicit change talk (aimed at ability) in this regard, asking “What’s something you’d feel pretty confident about trying now?” or “What would help you feel more confident about getting started?” and then reflecting and exploring client perspectives. Another parallel strategy is confidence scaling , using the same scaling approach as with importance, only this time focusing on confidence. An additional step with confidence scaling involves asking what would boost client’s confidence by a couple of points, which can help when moving to the next process of planning. 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. Even if not directly applicable to the current change topic, building clients’ sense that they are competent, worthwhile people with strengths and accomplishments, no matter how minor, can help them make difficult changes. 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. Clinicians can provide a recapitulation , or summary of the issues, focused on clients’ perspectives on the importance of making changes and their confidence, followed by a question such as “What now?” or “Where does this leave you?” The next step may include clarifying the goals of changing, and then exploring options for change with questions such as “What choices might you make?” or “Which options seem easier to try and more likely to succeed?” Clinicians now listen for mobilizing change talk and reflect and explore it. Mobilizing change talk relates to activation, or beginning to do something, and might sound like “I’m thinking about trying…,” “I might…,” or “I could….” Clinicians avoid pressing for firm commitment if clients are still tentative—and keep building momentum instead of risking turning clients away from 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. It is characterized by a collaborative, autonomy-supporting, and evocative style in which clinicians seek to understand clients’ perspectives, while directing clients toward considering changing one or more behaviors by building a sense of discrepancy between the current and hoped-for self, avoiding confrontation, and supporting clients’ optimism about the possibility and methods for change.
A Brief History of MI
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. Bill Miller’s exploration with Norwegian colleagues of his intuitive practice guided him to elucidate the principles underpinning his approach, which integrated cognitive and behavioral elements into a broadly client-centered style. Miller’s original principles were supplemented by collaborator Steve Rollnick’s observation that ambivalence was a central aspect of change, and that MI specifically targeted ambivalence. Working together, Miller and Rollnick developed the clinical methods and described them in their 1991 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. The first related theory was Carl Rogers’ theory of the necessary and sufficient conditions for therapeutic change, such as genuineness, congruence, and accurate empathy. A second related theory was cognitive dissonance theory, in which Festinger posited that people would work to reduce thoughts that were strongly dissonant with their behaviors by altering either their attitudes/thoughts or their behaviors. 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. A third related theory was Bem’s self-perception theory, in which people observed themselves, their behaviors, and their statements, and inferred from those actions what they believed and valued.
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. Rather than disseminating MI through writing only, Bill Miller and Steve Rollnick personally trained the first generation of MI Trainers. 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 2008.
Theoretical Concepts and Emerging Models of MI
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. Therefore the principles, goals, techniques, strategies, and terms of MI follow from the founders’ decisions, which may be influenced by data or practice or by exposure to other ideas. If the founders are the sole arbiters in defining MI, it is whatever they say it is, and elements may be added or deleted based on their preferences.
From the clinical research perspective, MI may be viewed instead as a set of attitudes, techniques, and strategies that can be described in a manual and can be evaluated with measures of treatment fidelity. This clinical research perspective focuses on sharp boundaries, specified timeframes, clearly defined strategies and techniques to address specific target behaviors, and attempts to isolate the unique elements of MI. The clinical research definition of MI results in a binary decision in that either MI is being done or MI is not being done. From this perspective, that MI is a specific definable intervention, a provider could be seen as doing MI in some sessions and not others, or possibly during some moments and not others.
Yet another perspective is the practitioner’s angle. Practitioners might view MI as an overarching counseling style, a general way of working with clients. The practitioner using this style weaves whatever strands are most useful in the moment, no matter where those elements might have originated (in MI, in adaptations of MI, or in similar or complementary therapeutic approaches, disciplines, or experiences). From this perspective, practitioners may see themselves as doing MI even when a video sample of a discrete moment in therapy might show them to be providing a cognitive-behavioral therapy–derived intervention, albeit in an MI-consistent style. In such practice, a decision rule might be “can one smoothly transition in and out of elements borrowed from elsewhere?” The provider may be exploring ambivalence with a client and notice a bit of distorted thinking, slip unnoticed into working with the client on exploring the background of that thinking or its fit with reality or rationality, and then slip back out and back to exploring ambivalence. To the practitioner, this whole session may be thought of as MI if MI’s spirit and techniques are present and if the client’s responses indicate that the therapeutic alliance is steady.
A fourth perspective is that MI is a set of ideas or concepts that originated with Miller and Rollnick but are now independent from them. A conceptual perspective might define MI as a set of specific ideas that fit into a nomological net, a framework of logically coherent and connected constructs into which empirical and practice findings are placed and interrelated. A conceptual perspective on defining MI may be based less on either need for clear definition and fidelity to that definition, as in the clinical research perspective, or need for pragmatism and devotion to doing what works best in the moment, as in the practice perspective.
MI as an Activator of Autonomous Motivations and Growth
MI seeks to build internal motivation to change, even in the context of clients seeking to change due to some duress or external situation. Individuals with higher levels of internal motivation for change may be more likely to succeed in achieving and maintaining the desired change. MI seeks to elicit the person’s healthy aspirations and propensity for positive growth. These aspirations and growth experiences are often internally motivating rather than resulting from external reinforcement alone. These goals of activating intrinsic motivations overlap somewhat with self-determination theory. Self-determination theory posits an alternative to some views of human motivation as originating in physiological needs, or as a drive state seeking to amend deficits. Instead, self-determination theory proposes that growth-oriented activity is the central source of motivation. Self-determination theory states that people have innate needs for competence, relatedness, and autonomy, and that these needs can explain intrinsic motivation. Self-determination theory proposes that motivation becomes internalized naturally because humans are ready to internalize ambient values and regulations. Individuals come to grasp the importance of social values as children. Over time, they transform observed social mores into personal values and self-regulation. Self-determination theory proposes that internal motivation is most likely when a person has a sense of efficacy, control, or self-regulation with regard to the required behavior. Self-determination theory outlines a continuum of motivations ranging from externally regulated to truly intrinsic. Markland and colleagues propose that MI is not focused on truly intrinsic motivations (defined by self-determination theory as engaging in behaviors because they are inherently interesting or enjoyable). Rather, MI focuses on a broader range of autonomous motivations regarding behaviors that lead toward desired outcomes for the person. These outcomes may involve extrinsic gain or increased coordination with one’s values and self-identity.
MI as a Method to Move People Through Stages of Change
MI is a counseling style concerned with encouraging behavior change. The transtheoretical model is a model of how people make deliberate changes, especially when it comes to eliminating problem behaviors and beginning new, healthier behaviors. The most well-known aspect of the transtheoretical model is the Stages of Change model, in which behavior change is seen as a process that progresses from low awareness and no intention to change through high awareness and active efforts to initiate or maintain change. The five stages of change are precontemplation, in which people may not recognize their behavior as problematic and are not planning to change; contemplation, in which people are considering change but remain ambivalent because there are also benefits resulting from their current behavior; preparation, in which people have decided to make a change and are making plans to change; action, in which people are actively taking steps to change, and maintenance, in which people are integrating the new behaviors into their ongoing lifestyle.
Although distinct, the transtheoretical model and model of stages of change and MI “grew up together” and complement one another. Specifically, MI is a valuable approach to use when people are in the early stages of change, to build interest and motivation for change. The concept of stages may be better as a heuristic than as a reflection of reality. In clinical encounters, readiness for change can fluctuate within a single discussion about change. By maintaining a client-centered perspective and eliciting client readiness to change rather than attempting to use pressure to motivate change, the provider using MI can avoid evoking resistance that can inadvertently be elicited by getting ahead of the client.
MI as an Activator of Emotions and Openness
Most descriptions of MI and its work with ambivalence have focused on cognitive rather than emotional elements. The resolution of ambivalence is seen as a cognitive task, as in reaching a decision about which choice to make. MI techniques have been described in cognitive and behavioral terms, as means to positively resolve tension created by unresolved ambivalence about change. Wagner and Ingersoll presented an alternative conceptualization of MI. Elicitation of negative emotions (e.g., by developing discrepancy) helps clients by narrowing their focus to areas in which they feel discontent, which leads toward them wanting to escape from the current unsatisfactory situation or avoid a future unsatisfactory situation. In contrast, the concept of positive reinforcement involves seeking positive states through behaviors that lead toward more satisfying conditions. From this perspective, motivation involves a desire to experience positive emotions. A positive emotions model encourages a view of motivation that emphasizes opening up to new experiences and actively seeking to build resources to support change and is consistent with the Broaden and Build model of positive emotions in motivation. Elicitation of the positive emotion of interest may lead to greater openness to experiencing. When a client experiences interest (or related emotions such as wonder or curiosity), his or her cognitive focus broadens to consider options that previously had been overlooked or rejected. This increased flexibility in conceptualizing situations may then facilitate resolution of ambivalence and increased openness to engage in activities that lead toward change. As the person acts in the newly considered direction, he or she may improve certain skills and increase the likelihood of achieving a desired outcome. Movement in this positive direction may increase confidence, sense of accomplishment, self-esteem and mood, thus establishing these increased resources for the person to draw upon in service of even more profound changes. After analyzing common MI techniques and strategies through the lens of the broaden-and-build model, Wagner and Ingersoll concluded that MI elicits positive emotions of interest, hope, contentment, and inspiration by inviting clients to envision a better future, to remember past successes, and to gain confidence in their abilities to improve their lives.
MI as an Interpersonal Intervention
Interpersonal theory and research suggest that interpersonal interactions can be represented by two orthogonal (perpendicular) dimensions: control and affiliation. The control dimension ranges from Dominance to Submission, whereas the affiliation dimension ranges from Warmth/Friendliness to Coldness/Hostility. When plotted, they form a circle that represents how controlling and affiliative a person is in interactions with others. Considerable evidence exists to support the idea that a friendly interpersonal style elicits reciprocal friendly responses from others and a hostile interpersonal style also elicits a reciprocal, hostile response. Interpersonal theory also suggests that a dominant interpersonal style pulls for complementary submissive behavior, whereas submission pulls for complementary dominant behavior. However, although dominant behavior may pull for submissive behavior, it often elicits reciprocal dominant behavior as interactants struggle for the upper hand in a relationship.
Interpersonal theory has psychotherapeutic implications. Although submissive and friendly submissive clients may pull for and respond well to dominant and friendly dominant clinicians, clients having other baseline styles may not react as well to such a therapeutic stance. Clients presenting with hostile-dominance, who may be angry and lashing out, are unlikely to respond well to a provider who attempts to assert control or dominance over the interactions, even in a friendly dominant manner and even though this is a logical stance to take if the provider believes that the client’s aggression must stop. Although being friendly and easygoing may be difficult to do in this situation, it is more likely to pull the client toward a friendly stance him or herself, which is likely to be more productive in moving forward. In contrast, with a client who is clinging and submissive, clinicians may be pulled to provide reassurance, structure, and direction, yet this is likely to reinforce the client’s needy behavior. Instead, a provider may take an interpersonal stance that pulls for the client to become more assertive and assume greater ownership of his life, even though the client may be pulling for the provider to take a dominant stance. Fig. 39.1 shows an interpersonal circumplex with hypothetical MI-congruent provider behavior and client responsive behavior.