How Motivational Interviewing is Used in Health and Wellbeing Services

Introduction

Motivational interviewing (MI) is a behaviour change technique that has evolved, initially at least, from experience in the treatment of alcoholism. While the concept of MI was first described by William R Miller in 1983 in an article published in Behavioural Psychotherapy, it was further developed by Miller and Rollnick (1991), where it was applied to people preparing to change their addictive behaviours. Today, MI is widely used in many professions as a tool to support successful behaviour change, including health and medical settings, criminal justice, education, counselling, leadership, management, and many more. In the active leisure sector, exercise referral schemes widely encourage the use of motivational interviewing to support clients with long-term conditions.

In the context of health and wellbeing coaching services, MI has become an integral tool that is used to support effective behaviour change. Specifically, MI is a therapeutic communication style that uses cognitive behavioural strategies tailored to the individual’s stage of change.

MI differs from other patient-centred counselling approaches in that it is directive, the focal point being to facilitate behaviour change by exploring and resolving ambivalence. MI is a popular method of interacting with a client to help encourage behaviour change. The process is aimed towards helping a person to resolve their ambivalence to change (Rollnick, 1995). Ambivalence being those mixed feelings about change, where they can see benefits for and against, but don’t take action.

Ambivalence to Change

When considering a change to habitual behaviours (e.g., whether to start exercising), people typically weigh up the advantages and disadvantages. Motivation to change will usually come from any perceived disadvantages of their current behaviour(s) alongside any apparent benefits of they’d expect to realise by making the change.

Most people are ambivalent about changing their habitual behaviours, even though they may know cognitively that it would be in their best interests (e.g., for their health, financially, relationships) to do so. Their approach, which is to avoid conflict (with themselves) is common, and will often involve statements like “I want to do more exercise, but I feel embarrassed that everyone will be looking at me because I don’t know what I’m doing”.

Ambivalence is one of the main things that keeps people stuck in their current (often familiar and comfortable) circumstances. It also explains why they struggle to make simple lifestyle changes to improve their health and wellbeing, even when they want to.

With MI, practitioners explore the client’s ambivalence, their resistance to change, and support the individual to find a solution in their own way. The technique is guided by a number of key principles (principles of motivational interviewing), including expressing empathy, developing discrepancy, rolling with resistance, and supporting self-efficacy (Miller and Rollnick, 2002). It is important for MI practitioners to understand that being empathetic does not mean that they agree with their client’s perspective or rationalisations. It simply demonstrates that the practitioner has a cognitive and emotional understanding as to why the client feels the way they feel and is able to help through communication.

Research in the discipline of MI suggests that adopting ‘accurate empathy’ is a significant factor in determining a positive client response to the intervention. In reality, ambivalence to change is actually quite normal and practitioners should ensure that their clients understand this.

In MI, practitioners seek to develop discrepancies between the client’s goal(s) and their current behaviours, using a range of techniques (open questions, affirmations, reflective listening and summary reflections – OARS), in an empathetic and client-centred manner.

Motivational Interviewing and Resistance to Change

Another key feature of motivational interviewing is the absolute avoidance of engaging with any conflict, argumentation, or correcting of the client’s statements. Informing a client that they are wrong or misinformed simply isn’t the best way to get them to change. After all, people generally don’t like being told what to do, or that they are wrong, even when they are. A natural response to situations like this is to push back, or apply resistance.

In MI, practitioners seek to ‘roll with resistance’ rather than confront it, although where it is necessary to do so, and only with the permission of the client, statements or information may be reframed to create a new momentum for change. This approach has a much more positive effect on an individual’s self-efficacy, raising their perceived ability to be able to make the change(s).

Like other person-centred approaches, MI is rooted in the underlying belief that people, including those around them offering support (e.g., family, friends, colleagues), have their own expertise and strengths, are resourceful, and have the capacity to develop their own solutions when the appropriate support is available. MI is simply about unlocking the motivation to make those changes by removing ambivalence and resistance.

The Spirit and Values of Motivational Interviewing

Motivational interviewing is associated with a number of key values and principles which together define the spirit of the approach. These include, but are not limited to:

• The motivation to change is elicited from the client; it’s not created, it was already there and the practitioner simply helps the client to find it.
• Only the client can identify and resolve ambivalence – the practitioner can help the client to find both sides of the ambivalence argument, but only the client can reach the outcome that will lead to a change in behaviour.
• Direct persuasion is not an effective method for resolving ambivalence – this generally results in client resistance and diminishes the prospect of behaviour change. Persuasion, aggressive confrontation, and argumentation are the theoretical opposites of motivational interviewing.
• The practitioner’s communication style is generally quiet, calm, and curious about what the client thinks and feels about their circumstances.
• The practitioner directs the client through open questioning techniques and reflective statements/summaries, helping them to examine and resolve ambivalence. Strategies of motivational interviewing are designed to elicit, clarify, and resolve ambivalence in a client-centred counselling atmosphere.
• The therapeutic relationship between the client and the practitioner is more like a partnership or companionship instead of the conventional expert – patient role. The practitioner respects and values client autonomy regarding their freedom to choose, and be responsible for, their own behaviour.

Summary

Motivational interviewing is an effective tool for any professional supporting clients with behaviour change, whether that be exercise, nutrition, smoking cessation, or any other aspect of human behaviour that has become habitual and counterproductive to improved health and wellbeing. If you are interested in learning more about motivational interviewing, you can take a look at our motivational interviewing course that has been specifically designed for health and wellbeing professionals. We also comprehensively feature a range of motivational interviewing approaches that can be used by practitioners in our Health and Wellbeing Coaching programme.

References

Miller, W.R., Motivational Interviewing with problem drinkers. Behavioural Psychotherapy, 1983. 11. 147-172.

Miller, W. and S. Rollinick, eds. Motivational Interviewing: preparing people to change addictive behaviours. The Guilford Press. 1991: New York.

Prochaska, J.J., J.F. Sallis, and B. Long, A physical activity screening measure for use with adolescents in primary care. Archives of Pediatrics & Adolescent Medicine, 2001. 155. 554-559.

14. Rollnick, S., What is Motivational Interviewing? Behavioural Cognitive Psychotherapy, 1995. 23. 325-334.

Miller, W.R. and S. Rollnick, Motivational Interviewing: preparing people for change. 2nd Edition ed. 2002, New York The Guildford Press.

Rollnick, S., et al., Development of a short “readiness to change” questionnaire for use in brief, opportunistic interventions among excessive drinkers. British Journal of Addiction, 1992. 87. 743-754.