Motivational Interviewing

Motivational interviewing (MI) is a collaborative and goal-oriented treatment practice for strengthening motivation and commitment to a particular goal. MI pulls from various therapeutic styles and theories such as humanistic therapy, cognitive dissonance theory, therapeutic relationship building, stages of change models, and positive psychology. Together, the patient and interviewer use reasons for change directed by the patient to address ambivalence and turn the desired goal into reality.^{4, 7}

It is the interviewer's job, through reflective listening, to implement MI's CORE Interviewing Skills and help patients navigate their way out of hesitation, propelling forward into change. These interviewing skills build the acronym OARS:⁷

Open Questions—asking open-ended questions

Affirmations—accentuating the positive

Reflective Listening—reflecting back what is said

Summarize—collecting and linking what is said with the focus of change

Client and therapist move loosely through four overlapping processes in the motivational interviewing experience.⁷

1. Engaging—building a therapeutic relationship between interviewer and client
2. Focusing—maintaining a specific direction in change talk
3. Evoking—eliciting the client's own motivations for change
4. Planning—developing a commitment to change and establishing a plan of action

Motivational interviewing processes of change are built off of Prochaska and DiClemente's stages of change model focusing on ambivalence.⁸ Moving through each of the processes can create hesitation—a factor that can stand in the way of change. MI's CORE Skills are used to bring the person closer to arguments for their desired goals, rather than strengthen their arguments for resisting change.⁷

The process of creating change is driven by four key elements that are the spirit of motivational interviewing:⁷

1. Partnership
2. Acceptance^{9, 10}
3. Compassion
4. Evocation

Partnership emphasizes the therapeutic relationship between the interviewer and the client. By building a strong and collaborative relationship with patients, MI therapists reduce resistance to change and increase motivation.

Acceptance comes from the work of Carl Rogers and incorporates (1) Absolute Worth, (2) Autonomy, (3) Accurate Empathy, and (4) Affirmation.^{7, 9, 10} Each aspect of acceptance characterizes the patient-centered focus of the model. Absolute Worth affirms each client has inherent worth as a human being and that his or her experiences matter. Autonomy describes the self-directed approach led by the client. Accurate Empathy is the active interest the therapist invests in understanding the patient's perspective. Affirmation seeks and acknowledges strengths and efforts the patient exhibits in his or her changing behaviors.

The third element of the spirit of motivational interviewing is compassion. To be compassionate is to promote the patient's welfare and give priority to his or her needs, engendering trust from the patient.⁷

Lastly, evocation means to bring about the strengths and resources the client already has. The belief of MI is that the patient innately has what is needed to resolve the ambivalence of change.

History of Motivational Interviewing

In 1983, William R. Miller wrote about an interpersonal process in working with problem drinkers.⁶ In Miller's experience, the relationship between therapist and client was frequently confrontational, eliciting denial and avoidance of further discussion. MI developed as an intuitive approach to confronting denial in counseling alcoholics by using well-established principles of motivation and social psychology.⁶ Some of the principles are based on Carl Rogers's client-focused counseling approaches from the 1950s. Miller incorporated some of Roger's nondirective, yet person-centered principles and developed a motivation process using Prochaska and DiClemente's stages of change model.^{14, 17}

Motivational Dialogue

Motivational dialogue (MD) is the communicative style used in motivational interviewing, often called "change talk."¹⁴ It sounds similar to engaging in a natural conversation with someone, adding a constructive guiding style led by the interviewer. This dialogue is used to motivate, point out, collaborate, elicit, and encourage patients to work through the challenges that prevent change by working through their problematic behaviors. Motivational dialogue is used in versatile addiction treatment settings and contexts such as a brief intervention, check-up, or traditional therapy sessions.¹¹

Varieties of Motivational Interviewing

Motivational interviewing is used throughout the differing stages of substance use disorder treatment. It has been used as prevention, a prelude to more intense treatment, in combination with other therapies and as a stand-alone therapy. MI has also developed into a stand-alone treatment titled motivational enhancement therapy (MET).

As a variable treatment modality, MI's methods have been applied to a myriad of formats and stages of substance use disorder treatment. Its approaches have been practiced as a brief intervention, family-systems therapy, and MET. The ease and adaptability of this client-centered counseling style has demonstrated its usefulness wherever ambivalence prevents a commitment to change.

Brief interventions often use motivational interviewing skills as one of the techniques to disrupt a problematic situation. A brief intervention is a time-limited and discrete conversation that raises awareness of a problem and encourages the patient to consider steps to address it. This is generally done in one to two sessions within the early stages of recovery. ^{5, 14, 17}

Systemic-motivational therapy is a variation of motivational interviewing piloted as a multi-person approach. This modality adapts family-systems therapy—which focuses on relational issues impacting substance use disorder—to the framework of MI. A family belief system developed to manage/solve/neutralize problematic behaviors of the person misusing substances may be stuck in ambivalent beliefs that stand in the way of change. Addressing the barriers of ambivalence for change within a family system may take away the environmental instigators of substance use.¹³

Motivational enhancement therapy is a stand-alone treatment involving the skills of MI plus additional feedback. The more traditional type of therapy adds an assessment interview, personal feedback of assessment results, and exploration of problems the client has experienced. There are two types of MET: (1) a brief treatment of four to six sessions that may be sufficient in itself; and (2) as a motivational catalyst designed for the nontreatment seeker at an early stage of readiness to change.¹⁴

Population

Motivational interviewing is effective for problem drinkers, substance misusers, and people who demonstrate resistance to changing problematic behaviors. Severity of problem, gender, and age do not affect treatment outcomes.⁴ However, there is a greater effect on outcomes in general among minority populations. Literature suggests MI is based on a nonconfrontational therapeutic style and may present a more culturally respectful modality of therapy.³ MI does not work best for young children or cognitively impaired individuals because of the necessary higher order mental functioning demands.⁴

Patient Profile

The typical patient receiving motivational interviewing for drug or alcohol addiction is wary about changing his or her destructive behaviors for healthier ones. A patient receiving MI could be any race, gender, age (except a young child), at any level of recovery, attending any service for addiction treatment, and unsure whether they have a problem at all. MI is designed to start wherever the patients are, building on their ideas for change, and progressing at their own pace. MI-based treatments do not have a set number of sessions, but generally clients and interviewers meet one to four times.

Motivational Interviewing Outcomes

Research suggests that MI is an effective treatment modality for substance use disorder. Its applications as a treatment philosophy provide a set of methods that can be used to generate a spirit of motivation and positive change alongside a wide variety of modalities. It can be used in a wide range of patient populations, is adaptable for various levels of care, and is as effective as other gold-standard treatments for substance use disorder. Motivational interviewing is named an evidence-based practice (EBP), reporting efficacious outcomes in over 300 peer-reviewed research studies.

In one of the largest analyses done on motivational interviewing’s overall effectiveness, researchers reviewed over 115 studies to sum the average effects that influence MI outcomes.⁵ They examined treatment length, the most effective time to use MI, diverse deliveries of MI, manual use, ideal populations, specific problematic behaviors, and use with other evidence-based practices and levels of care. Results varied slightly between study and format, but overall they were able to generate the following effects of motivational interviewing:

• MI was effective for 75% of all participants, significantly effective overall compared to no treatment, and as effective as other evidence-based treatments for substance use disorder (e.g. cognitive-behavioral therapy, Twelve-Step Facilitation);⁵
• MI is most effective when used as a prelude to other treatments or in addition to other treatments;¹⁰
• MI is typically completed in one to two sessions and/or four to six sessions with MET. Research is unclear on ideal treatment length; however, more sessions tend to lead to better long-term outcomes;⁵
• No MI manual use in sessions is significantly more effective than strict use of a manual;⁵
• MI is ideal for all populations regardless of gender, age, or problem severity and shows the greatest impact in minority populations when compared to other common substance use disorder treatments;⁵
• MI can increases client engagement up to 15 % and increase treatment retention when given at intake assessment.^{1, 2}

A large body of research supports motivational interviewing as an effective evidence-based practice. MET displays the most significant results and is recommended for use in targeting specific behavioral changes as a stand-alone treatment. Basic MI research illustrates its effectiveness as a prelude to other treatments or combined with additional psychotherapy techniques or modalities. Diverse and adaptable, MI shows positive outcomes in validity, reliability, and potential to be carried out in a multitude of settings and contexts.

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