# Motivation and emotion/Book/2016/Motivational interviewing

* Multimedia presentation (3 min)

## Overview

* Case study 1
* Jeff has a problem, why does he not change? Does he fail to see how serious his situation is? Everyone can see that Jeff is physically unhealthy but he refuses to exercise and he eats poorly. Is it that he lacks the knowledge to understand that he is destroying his health? Does he lack the motivation to do something or does he simply not care?
Many health professionals ponder such questions when trying to help patients in a health crisis to change their behaviour. But hesitancy to change is part of human nature (Hettema, Steele & Miller, 2005). Clients presenting to health clinics for help exhibit a wide range of readiness (Miller & Rollnick, 2013). Eight out of those ten in need of change are ambivalent about change (Miller & Rollnick, 2013).
According to Prochaska and Diclemente’s transtheoretical model, behaviour changes encompass a cycle of stages of change: precontemplation, contemplation, preparation, action and maintenance. At the precontemplation and contemplation stages, people often wonder about change, but they don’t act. The primary goal then is for therapists is to help clients overcome the hesitation hurdle in the direction of change (Hettema et al., 2005; Miller, 2004).
This chapter discusses how to utilise motivational interviewing (MI) to resolve ambivalence towards change and thereby to elicit behaviour change. It will start with elucidating what MI is, what are the underlying theories and applications of MI in the real world, especially in the health care settings.

## What is Motivational Interviewing (MI)?

MI is a client-centred counselling style to enhance personal motivation for behaviour change by exploring and overcoming 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 trans-theoretical 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 initial 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).

## History of MI

MI was introduced by William Miller and Stephen Rollnick in the 1980s when treating patients with alcohol abuse. At that time alcoholic clients were perceived as deceptive and unreliable, such that counsellors had to impart knowledge, insight, and motivation for change. Counsellors took an authoritarian position and commonly questioned clients’ wrongdoing in a confrontational style. Counsellor-domineering approaches such as disagreeing/arguing could lead to higher level of client resistance, and thereby jeopardise the quality of therapeutic treatment (Miller, 1996). Based on the trans-theoretical model, clients who entered the help program might have not yet committed to change, or still felt ambivalent about change (Miller & Rollnick, 2009).
Therefore, Miller believed the priority was to evoke clients’ motivation for change. He advocated an empathetic, client-centred counselling style. More attention was drawn to strengthening clients’ own words for change. Clients under William Miller’s care achieved double the rate of total abstinence at 3-month and 6-month follow-ups compared to other clients who were not receiving MI. Furthermore, clients that received MI were more likely to comply with the treatment and were more motivated for change (Miller & Rose, 2009). Later MI was combined with assessment feedback, resulting in the formation of motivational enhancement therapy (MET). Nowadays, MI and MET have been implemented in various fields, such as cardiovascular rehabilitation, diabetes management, dietary change, hypertension, infection risk reduction, gambling, and smoking (Miller & Rose, 2009).
| Previous Approach | Miller's approach |
| This person ought to change | This person wants to change |
| A tough, confrontational approach is always the best | A negotiation-based approach is the best |
| I'm the expert, I know everything, e.g., I know what you need | I need to evoke the client's intrinsic motivation for change, e.g., You have what you need |
Table 1. A comparison between Miller's new client-centred approach and previous dictatorial approaches

## Theoretical basis of MI
### Self-determination theory

Self-determination theory is relevant to understanding how to overcome a lack of motivation. Simply put, Self Determination Theory considers how much ownership an individual places on their own ability to be successful and overcome life’s challenges – are they in control or do they let others control them? The individual’s awareness of their own competence, autonomy and relatedness are integral (Markland et al., 2005) to deciding if there is sufficient motivation. A self-determined individual feels in control of their own destiny and so, they will likely attend counselling with the motivation to want to change. Motivational Interviewing fits nicely within that theoretical framework as it is recognised as a technique for overcoming ambivalence and relevant for those who lack self-determining qualities. When a counselling client appears to lack the motivation to undertake a change process and a counsellor needs to get a handle on their openness to change, MI presents as a useful technique (Marker & Norton, 2018).

### Client-centred counselling

MI is influenced by Carl Rogers' client-centred psychotherapy which emphasises the positive human potential (Miller, 2004). Given the appropriate empathic understanding, unconditional positive regard, and radical acceptance, people will naturally move towards a healthy, self-fulfilling state (Hettema et al., 2005). 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

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 Client-Therapist Relationship
### Partnership

MI advocates an egalitarian relationship between the therapist and the client (Miller, 2004). Instead of the therapist being the superior expert exhorting what is right, the therapist recognises the client’s hidden capability in knowing what one wants, what works best to achieve that (Miller & Rollnick, 2013). The therapist here is to use his/her expertise to create a supportive interpersonal relationship in which the client is to be aspired for free aspiration[say what?] (Miller & Rollnick, 2013). Miller portrays MI as a dancing partnership, in which both members in the group collaborate together, with one leading the direction in the movements gracefully without coercion (Miller & Rollnick, 2013). Not surprisingly, this partner-like relationship requires a profound respect to the other. Analogically, running MI is like flipping through a client’s life photo album; it is to understand the world through the client’s point of view, not to dominate the entire process or to offer expert opinion on how to live a rightful way (Miller & Rollnick, 2013).

### Acceptance

Acceptance in MI does not refer to the therapist’s personal approval. Acceptance has four aspects (Miller & Rollnick, 2013):
Elements of Acceptance :
| Absolute worth | generalised caring and unconditional positive regard, recognising every individual as a complete, separate human being who deserves basic respect and trust. A person can improve or grow towards an ideal direction when appropriate therapeutic conditions are provided. |
| Accurate empathy | a genuine and active interest in understanding the client’s insight (Note: sympathy is a feeling of pity, different to empathy). |
| Autonomy | acknowledges clients’ active involvement in decision making regarding when and how to change. The willingness to change must come from within the client, in agreement with the client's own interests and values. |
| Affirmation | acknowledges clients’ active involvement in decision making regarding when and how to change. Affirmation encompasses an understanding and recognition of the client’s effort and contribution in the therapy. |

### Compassion

In terms of ethics, compassion posits acting benevolently on the behalf of the client. It is to pursue the gain and welfare of the client and honestly puts clients’ need first. Only by doing so, can it ensure the other three aspects of the spirits are in place, and thereby an optimal atmosphere for evoking change is made possible (Miller & Rollnick, 2013).

### Evocation

The conventional authoritarian approach is based on a deficit model in which the client is being assessed and criticised, the therapist is to utilise the professional knowledge, expertise to correct that deficit (Miller & Rollnick, 2013). In contrast, Miller and Rollnick (2013) believe clients have enough resources and insights, and it is up to the therapists to uncover these abundant hidden resources within the clients (Miller & Rollnick, 2013).
| What to do | What not to do |
| Advocate equal relationship | Dominate the therapy session |
| Guide | Prescribe |
| Evoke intrinsic motivation and confidence | Tell the client why and how to change |
| Create an equal and acceptable atmosphere | Focus on the behaviour change at the cost of empathy |
| Actively listen and encourage change talk | Convince and hand down expertise knowledge/insight |
Table 2. Contrast between MI spirit and conventional therapy approach

## Person-centred guiding

These skills derive from Rogers' person-centred counselling aiming to convey the spirit of MI into real practice. There skills emphasise on active listening in order to establish a peaceful therapeutic alliance (Miller & Moyers, 2006). These skills are known as OARS: open-ended questions, affirmation, reflections, and summaries.

### Open-ended questions

Open-ended questions are more encouraged in MI than closed-ended questions as they serve the purpose of letting the client do most of the talking so that not only can the client’s insight and concerns be revealed, but more importantly, a peaceful, trustworthy therapeutic alliance can be established (Miller & Rollnick, 2013; Naar-King & Suarez, 2011).
Test yourself, is it an open or a closed question?
1
What do you like about drinking?
Open
Closed
2
Is it important to have meaning in life?
Closed
Open
3
Are you willing to come back for a follow-up visit?
Closed
Open :
However, too many questions in a row can have the opposite effect. People may feel they are being interrogated or interpret the questions as the questioner not listening to them (Naar-King & Suarez, 2011). The purpose is to start up a topic for exploration and then follows with other strategies. A skilful therapist should be able to recognise the most effective and appropriate strategies based on the situation and the client’s characteristics. For instance, some are generally talkative and, in this case, the therapist is to guide the exploration towards change talk. On the other hand, some may not like revealing and discontinue the topic where it is started. Therefore, it is up to the therapist to utilise the skill whenever is appropriate (Miller & Rollnick, 2013).

### Reflective listening

Miler considers reflective listening is one of the most important and challenging skills required for MI (Miller, 2004). It is frequently used to express accurate empathy and to understand the client’s interpretation of the real world. Reflective listening is not merely being quiet while listening, it is more about the way how the therapist responds to what the client says. The therapist can easily fall into the trap of inactive listening, which is defined as ‘roadblocks’. Some examples include: tell the person what he/she should do; warning; disagreeing/criticising; providing solutions; blaming/criticising; probing. What really behind the ‘roadblocks’ is the therapist diverts from the egalitarian partnership and the underlying message is do what the expert says (Miller & Rollnick, 2013). Below is an example illustrating how the therapist inadvertently sets up roadblocks while listening to a client discussing about an important decision.
   Client: I just don’t know whether to leave him or not.
   Therapist: You should do what you think is best. (tell the person what she should do)
   Client: But I don’t know what is best.
   Therapist: Yes, you do, in your heart. (disagreeing/criticising)
   Client: Well, I just feel trapped, stifled in our relationship.
   Therapist: Have you thought about separating for a while to see how you feel? (giving advise/providing solutions)
   Client: But I love him, it would hurt him so much if I left!
   Interviewer: Yes, if you don’t do it, you could be wasting your life! (warning/threatening)
   (Miller & Rollnick, 2013, p.72)
This exchange illustrates a poor running of MIing as ambivalence is not being explored, rather, the client has been pushed towards one solution. This is not a good example of reflective listening either, because the client is dealing with ‘roadblocks’ rather than be given the chance to fully express or explore (Miller & Rollnick, 2013).
Now let’s look at what a proper reflective listening is like. Here is an example looking at a problem drinker with ambivalent issues.
   Client: I worry sometimes I may be drinking too much for my own good.
   Therapist: You’ve been drinking quite a bit.
   Client: I don’t really feel like it’s that much. I can drink a lot and not feel it.
   Therapist: More than most people.
   Client: Yes. I can drink most people under the table.
   Therapist: And that’s what worries you.
   (Miller & Rollnick, 2013, p. 73)
Reflective listening is more like a statement guessing what the client means. Reflective listening is a very skilful technique. The therapist must hear the message correctly, it is not just what is said, more importantly it is what the client means. People do not always say what they mean, and it is up to the therapist to decode the words and find the underlying messages behind it. Unexperienced therapists may only be able to reflect on what the client just said, this can make the conversation run in circles. A competent therapist with good reflective listening skills can go deeper into the conversation resulting in a better understanding of what the client actually means (Miller & Rollnick, 2013).

### Summarising

The use of summarising is to reinforce those important points which have just been discussed, and to demonstrate to clients that they have been listened to intently, in order to prepare clients to express themselves further. There are three types of summary, and their purposes are listed below (Miller & Rollnick, 2013).
| Types of summarising | Explanation |
| Collecting | Often used in the process of exploring the situation that has brought the client to therapy so the therapist can get the whole picture. Often a collecting summary will end with a “what else” to prepare the client for further exploration. |
| Linking | Combines what the client has just said with new material. This is especially useful in addressing ambivalence as it offers client the ability to go back and forth, looking at reasons to change and compare them with reasons to stay the same. |
| Transitioning | Often used at the end of a session, before another session starts, to prepare client for what is going to follow next. |

## Elements of MI
### Responding to resistance

Resistance is inevitable in MI and its emergence usually indicates the client is not ready for the next step. When resistance arises, the therapist should acknowledge it and address accordingly (Miller & Rollnick, 2013). Resistance should be regarded as normal response and how well the therapist deals with resistance is going to hugely impact the treatment outcome. Studies have shown resistance happens early in the counselling predicted dropout from the treatment or the client is less likely to initiate change (Miller & Moyers, 2006). When resistance does occur, the therapist should step back, and acknowledge the clients’ emotions and perception and treat these as an opportunity to further explore clients’ needs rather than something to fight against. Here, the therapist needs to demonstrate good reflective listening skills, showing genuineness and empathy. Another approach is to go around the hurdle so to postpone the dissonance and to work on other issues that are less challenging (Miller & Moyers, 2006). No matter what the responses are, it is vital to ensure personal control. If this is not maintained, it will only further frustrate the clients leading to less compliance with treatments (Miller & Rollnick, 2013).

### Change talk

Change talk is a motivational statement which expresses intention to change, the disadvantages of the status quo, and optimism about change (Naar-King & Suarez, 2011). It implies that MI is working and how the client responds to it will determine whether the client is going to commit to change or stick with the status quo. The general technical approach toward change talk should be elaborating, reflecting, summarising and affirming (Naar-King & Suarez, 2011).
| Types of change talk | What is involved | Examples |
| Elaborating change talk | Encourage with particular interest and curiosity both verbally and nonverbally (e.g. pay attention, head nodding), | a. What else have you noticed? b. What are some other reasons you might want to change? |
| Reflecting change talk | Clarify what the client says, carefully select what to reflect upon in order to reinforce change talk | Client: “I want to quit smoking, but I don’t know if I am ready.” Therapist: “You really believe you want to quit, let’s try…” |
| Summarising change talk | Selectively gather and encapsulate client’s change talk, so that client can hear it again in a more condensed manner | Therapist: “You mentioned a few concerns about taking anti-depressants. You said your mood is better and have more energy while on antidepressants…” |
Table 3. Three types of change talk

### Commitment

This is the point when the client has summed up enough intrinsic motivation for change and it is time to strengthen commitment to a change plan (Miller & Moyers, 2006). It is important to recognise when the person is ready for change. Some of the cues can be used to tell when it is time to offer the change plan.
* Decreased resistance: Dissonance in the counselling diminishes
* Decreased discussion about the problem: less conversations on the concern
* Resolve: the client appears more peaceful, relaxed, open and settled
* Change talk: the client makes direct change talk, less satisfaction with the status quo, more look forward to a new start
* Questions about change: the client asks questions about how to implement change
* Envisioning: the client talks about what benefit will come after the change
* Experimenting: the client tries out change actions between sessions
Back to the essence of spirit of MI, it is always the client who decides what needs to be planned and done. The therapist’s role is to offer expertise when is asked for (Miller & Moyers, 2006). If the ambivalence re-emerges, do not force, instead, follow up with the person and leave the opportunity to the client. It is also helpful to use reflective listening and summarising skills to consolidate change talk (Miller & Moyers, 2006).

## MI in the real world
### Alcohol and substance abuse

Given the fact MI was originally designed to treat alcohol and substance abuse, many studies have concluded clients have significantly benefited from MI in terms of treatment retention, motivation, adherence, and positive outcomes (Hettema et al., 2005; William & Miller, 2004). However, Hettema et al. (2005) further pointed out in their meta-analysis study that using the same MI treatment and targeting the same problem can result in variance across different sites and populations. This also illustrates the treatment integrity can impact the treatment outcomes (Miller & Moyers, 2006). Particularly, therapists’ interpersonal skills can powerfully influence clients’ participation in the treatment (Moyers, Miller & Hendrickson, 2005). As Miller and Rollnick (2013) have strongly argued, to learn MI requires more than reading the manuals, as it is a complex skill that requires extensively progressive guidance and personal follow-up coaching.
Favourable treatment outcomes have also been documented when MI is used in addressing substance abuse and related problems (Burke, Arkowitz & Menchola, 2003; Hettema et al., 2005; Miller, 2004). Again, the observable effect sizes were around medium range and seemed to be sustained at 4-year follow-up posttreatments (Burke et al., 2003). Clients that received MI treatment benefited the most compared those on a waiting list, and those in the treatment as usual group (Burke et al., 2003; Hettema et al., 2005). It is noteworthy that smoking cessation has been less responsive to MI treatments (Burke et al., 2003; Hettema et al., 2005; Miller, 2004). It is possibly because there are legal implications behind drug abuse whereas smoking seems to be less debilitating therefore less fatal consequences (Burke et al., 2003).

### HIV risk behaviour

Studies regarding MI on HIV risk behaviour reduction offer mixed results. Miller (2004) revealed MI successfully reduced unprotected intercourse among women at high risk for HIV infection when compared to health education and placebo groups. On the contrary, Burke et al. (2003) claimed that, based on analysis of the current randomised trials, the yielded result was not statistically significant to suggest MI is more effective than placebo/education control group. They also mentioned the study in this area may not be reliable due to the small number of studies carried out, and that the four studies included in this meta-analysis all came from the same institute (Burke et al., 2003).

### Healthy lifestyle and cardiovascular disease

MI has also been implemented in promoting healthy life choice among participants with cardiovascular disease. A meta-analysis conducted by Thompson et al. (2011) concluded that although the power was low in this area, there are encouraging evidence showing MI is more efficacious than traditional information/advice in reducing BMI and hypertension among cardiovascular patients. This similar effect of MI was also demonstrated on 356 teenage girls in a 16-week physical education class. In this randomised experiment, MI was provided in conjunction with social support/self-empowerment sessions, lunch get-together and parent outreach activities. At the 9-month follow-up, girls in the intervention group showed increased participation in physical activity and higher self-efficacy in overcoming barriers to physical activity. Improvement was also observed in vegetable/fruit intake and regular breakfast eating (Neumark-Sztainer et al., 2010).

### Summary and future challenges

MI has higher statistically significant advantages in alcohol/substance use and healthy lifestyle promotions. MI has mixed results in HIV risk reduction and no supportive evidence in smoking cessation. MI can be delivered by a wide range of health care professionals, regardless of amount of training and supervision across various setting in different stages of disease (Lundahl et al., 2013).
Due to the lack of regulation, however, it is hard to ensure MI is being strictly followed in the real practice. In fact, many of the studies did not include careful evaluation of treatment integrity such as videotaping, ongoing supervision, and the skills of the MI administrator were not described or standardised (Burke et al., 2003).
The effectiveness of MI also proves to be different across different populations (Miller & Rose, 2009). Especially recipients from a minority group such as Native Americans showed more promising outcomes compared to White non-Hispanic Americans. This might because the spirit of MI resembles Indian Americans’ native culture style so that those clients were at ease when receiving MI (Miller & Rose, 2009).

## Conclusion

MI can be a useful counselling method with broad applicability in health care settings. It is particularly helpful in encouraging client motivation, especially where clients present as ambivalent to change. MI can be delivered as a free-standing intervention in 1-2 sessions. In spite of the moderate effect sizes in most of the clinical trials, MI still appears better than conventional intervention or placebo control group. When considering that MI elicits similar effect much quicker than other traditional therapies, MI may truly be more cost effective (Burke et al., 2003). In addition, Hettema et al. (2005) postulated refreshing sessions may be added at later follow-ups to bolster its long-term effect. Our understanding of MI is still at a preliminary stage as there are still lots of variability in delivering MI to different clients across many settings. The future focus of the research should be discovering other factors that can alter the efficacy of MI and more effective training programs can be developed to enhance the application of MI in more areas.