Principles of Motivational Interviewing for Health Coaching

Introduction to Motivational Interviewing

Motivational interviewing (MI) is a behaviour change and communication technique that has been used extensively by professionals working in behaviour change roles, including health and wellbeing coaching, medicine, nursing, exercise counselling, education, criminal justice, business, and social work to name a few. In the health and fitness industry, MI is also widely used to support clients who have long-term conditions (e.g., diabetes, obesity, hypertension). MI is a person-centred approach, which like similar approaches, is grounded in the belief that every individual has the capacity and responsibility to change their behaviour when they have appropriate levels of motivation and support.

Broadly, MI is about engaging with clients to develop a strong partnership based on trust and mutual respect, before exploring ‘with them’ (not for them), the changes that ‘they’ would like to make, and the reasons for ‘their’ ambivalence (arguments for and against change). MI practitioners use open questioning, affirmations, reflective listening and summaries (see below), to help clients develop the confidence and motivation to change.

MI is grounded in a set of key principles, which are each presented and contextualised below.

Principle 1: Express Empathy

Empathy involves seeing the world through the client’s eyes, thinking about things as the client would, and trying to share the client’s experience of the world.

The expression of empathy is critical to the MI approach because it develops trust and rapport, which must be established by practitioners before any discussions about making changes can take place. When clients feel that they are understood, they are much more able to open up to their own experiences and share those experiences with others. Having clients share their experiences in detail allows MI practitioners to assess when and where clients need the most support.

Importantly, when clients perceive that a practitioner is truly empathetic, they become open to gentle nudges, challenges, or experiments by the practitioner about their behaviour(s), and beliefs about those behaviours. Without empathy, clients are unlikely to be comfortable examining their ambivalence about change, and are more likely to be defensive or resistant to alternative approaches.

It’s important to stress that being empathetic doesn’t mean agreeing with the client… It simply means that the practitioner is able to see, feel and more importantly, demonstrate, that they understand, care, and that there is no judgement.

Principle 2. Develop Discrepancy

Motivation for change will present when people can see a discrepancy between their current behaviours and circumstances, and where they want to be in the future. This discrepancy serves as the fuel for motivation!

MI practitioners work with clients to create a situation where clients can identify for themselves that there is a clear discrepancy between their current actions and their future goals. The practitioner cannot reveal this to the client, even though it may be obvious, the client must arrive at this conclusion themselves, and the practitioner orchestrates this situation through intelligent and empathetic communication. When clients perceive that their current behaviours are not leading toward some important future goal, they become more motivated to make important life changes.

Discrepancy cannot be developed at the expense of other MI principles, but rather alongside others. In doing so, practitioners help clients to gently and gradually see and feel how some of their current ways of being may be pulling them away from what they want, rather than towards it.

Principle 3. Roll with Resistance

People instinctively don’t like being told what to do so the more forcefully they are advised, the more likely it is that they will resist or push back. In MI, the practitioner resists the urge to push back or highlight resistance, and simply ‘rolls with it’. To be clear, statements demonstrating resistance from the client are not challenged. Instead, the practitioner uses the client’s ‘momentum’ to further explore the client’s views and opinions on the subject.

With this approach, in time, resistance from clients tends to decrease because they learn that they can trust the practitioner, they are not being judged or lectured about the benefits of change, as often happens in other disciplines. As discussions evolve, clients relax a little more around the subject of change, and because they aren’t resisting or pushing back as much themselves, they aren’t reinforcing their own arguments for not changing. For many people, resistance is somewhat of a reflex response, so when the trigger for that is removed, so too is the response.

MI encourages clients to develop their own solutions to the problems that they themselves have defined. Thus, there is no real hierarchy in the client-practitioner relationship for the client to fight against – there is no expert, authority, or person of power. Power is shared by both parties and the practitioner simply guides the client in an exploration of their own knowledge, opinions, and feelings about change. While practitioners may, with the client’s permission, invite clients to examine new perspectives, they don’t impose a new way of thinking on clients.

Principle 4. Support Self-Efficacy

The extent to which a client believes that change is possible directly determines their self-efficacy – when there’s no belief there’s no hope – it’s a hopeless situation!

As MI conversations progress, clients become aware that they have the freedom to change, or not to change, and that’s their right. With this right, also comes the responsibility, both for changing the behaviour (or not), and the outcomes which follow (positive or otherwise).

MI practitioners focus on helping clients develop both their motivation and self-efficacy; a form of situation-specific self-confidence. MI practitioners reveal to clients through their open and non-judgemental communication style that they alone have to identify whether they want to change, what they want to change, and when… Once the client feels that they have sufficient motivation and efficacy, only then are conversations turned to the how.

Ultimately, practitioners support clients to back themselves, and believe that they have the ability to change if they have sufficient desire (discrepancy). For example, the practitioner might inquire about other healthy changes the client has made in their life, highlighting the skills the client already has in their change toolbox. Sharing brief clinical examples of other, similar clients’ successes can also be helpful.

Motivational Interviewing Skills – OARS

MI is by nature agile and flexible in terms of its structure. As such, there are no formal procedures, scripts, universally agreed methods to implement it. That said, MI is defined by a key set of skills that practitioners must become proficient with. These skills, which may also be called micro-counselling skills, are defined by the acronym OARS.

Open ended questions – these are questions that clients cannot answer with a simple “yes”, “no” answer, or a short “three times in the last week” response. Most people begin MI sessions with an open-ended question such as, “What brings you here today?” or “Tell me, what’s been happening since we last met?” Although closed questions are necessary at times, the open-ended question creates a forward momentum that is used to help the client explore change and their feelings around this. Reponses determine future questions from the practitioner, thereby ensuring forward movement.

Affirmations – these are statements of recognition about client strengths and abilities. Many people who seek assistance and support have failed previously with their change efforts. That is, they’ve tried to alter their behaviour and it didn’t work. As a result, clients attend feeling demoralised or, at least, suspicious of the assertion that change is possible. This condition means that practitioners must help clients to feel that change is possible and that they are capable of implementing that change. They do this by uncovering previous successful events, even if only maintained for a short while, and illustrating to clients that they do have the capacity to do this.

Reflections – also known as reflective listening, practitioners listen carefully and attentively (without interrupting) for signals that the client is opening up to the possibility of making a change (e.g., “I suppose I could take another look”). This is known as change talk and tends to build in volume as the client starts to feel more motivated about making a change. MI practitioners listen carefully before reflecting statements back to their clients, often reframing them to illustrate that they have been heard and the practitioner believes in them. Reflections are used by practitioners to guide the client towards resolving their own ambivalence by questioning (therefore highlighting) the negative aspects of their current behaviours. Reflections can be simple, like a brief statement to reinforce what has been said, or complex, which might be more of a paraphrase of more detailed or complicated information that has been shared by the client.

Summaries – these are a more comprehensive plenary of what has been discussed, but operate in much the same way as a reflection, reinforcing to clients empathy, understanding, and belief and respect in their ability and freedom to choose. Summaries often highlight both sides of a client’s ambivalence and promote discrepancy by highlighting key change language, and minimising or excluding sustain talk (reasons for not making the change).

Summary

Motivational interviewing is a powerful tool for people working with clients to empower behaviour change. As an intervention, it’s necessary to undertake a high-quality initial motivational interviewing training course, and then also participate in ongoing reflective practice and supervision from a more experienced practitioner, or trainer in MI. The intervention is used widely in both clinical and non-clinical settings, and throughout the fitness industry. It’s also commonly used in health and wellbeing settings and exercise referral programmes. Those seeking to implement MI into their coaching practice without attending any formal training should undertake extensive reading to broaden and deepen their understanding, and attempt to practice some of these skills socially and more informally before using them with real clients. Knowledge of MI alone will not make a person effective at using the technique, it must be used, refined, and developed like all skills over time.