MOTIVATIONAL INTERVIEWING
Motivational Interviewing (MI) is a therapeutic technique used to address addiction and
substance use disorders (SUD) in patients by strengthening one’s motivation and commitment to
a particular goal, such as sobriety. When battling an addiction, one of the most difficult hurdles
to overcome is a lack of motivation.
Despite the inevitable health issues, financial costs, and social and legal consequences of
substance abuse, the idea of living without drugs or alcohol can be intimidating. The idea of
giving up one’s drug of choice can outweigh these negative consequences, ultimately resulting in
a lack of true motivation to get sober. For others, a pessimistic attitude keeps them from
recovery. They feel like sobriety is not a realistic goal, that they do not need to quit because they
aren’t ready, or it will be too hard.
The perspective is different-you adopt a different style from solving problems for people to
encouraging them to solve them for themselves. That’s what Motivational Interviewing is
focused on.
4 KEY CONCEPTS:
1) First, the sessions themselves are called interviews. Rather than a confrontation by a
therapist, it is considered a collaboration between the facilitator and the patient.
2) Next, patients are encouraged to create their own goals as opposed to a therapist trying to
impose sobriety or whatever the therapist believes their patient needs. When individuals
in recovery feel as though they are the one in control of their own recovery, it encourages
them to continue setting goals and be self-motivated moving forward. This is very
effective when trying to achieve long time sobriety.
3) This leads to the third concept: the patient’s autonomy. Oftentimes, going to treatment
can feel like a surrender of a patient’s freedom to the authority of their therapist. MI
focuses on making sure that patients feel empowered, as the true ability for making
changes lies within the patient, not within the therapist.
4) MI does not focus on the underlying causes of an addiction, such as past traumas or
mental illnesses.
4 PROCESSES OF MOTIVATIONAL INTERVIEWING:
1) ENGAGING: One of the most imperative aspects of Motivational Interviewing is
establishing a strong and trusting relationship with a client. Therapists and clients must
form an alliance of sorts, working together towards a client’s self-realized goals. This
alliance is strengthened through mutual respect and focused on the client’s own strengths.
Counselors must be empathetic and make sure that the client knows that setting and
working towards goals is a collaborative effort. This ensures that the assumed power
dynamics of a counselor-patient relationship does not diminish the patient’s sense of
control over their own recovery.
2) FOCUSING: In the focusing phase of Motivational Interviewing, the counselor helps the
client determine what is truly important to them and what they want to get out of going to
treatment. Using this information, the counselor can set the tone for their sessions moving
forward and help their patient find their own desire to change. While these goals should
be mutually agreed upon by both the patient and their therapist, it is key that with MI the
patients themselves do the work of identifying their own problems and set goals
accordingly. The focusing process provides an opportunity for the therapist to narrow the
conversation to the topic of patterns and habits that the client ultimately wants to change.
3) EVOKING: The evoking process of Motivational Interviewing involves uncovering a
client’s personal motivations for change. After finding their focus, a facilitator must
address and bring their patient’s attention to why they want to recover. Therapists must
recognize even subtle instances where their client brings up their desire to change and
bring attention to this internal motivation. Inciting this “change talk” in clients and
bringing out their own arguments and motivations for recovery is the most unique and
important aspects of MI. During this phase, the therapist increases their client’s sense of
the importance of change, confidence that change can occur, and readiness for change.
Once a patient is engaging in change talk, it is the counselor’s job to reflect and
summarize what they are saying.
4) ROLLING WITH RESISTANCE: The third principle, rolling with resistance, means that
the counsellor does not fight client resistance, but "rolls with it." Statements
demonstrating resistance are not challenged. Instead the counsellor uses the client's
"momentum" to further explore the client's views.
5) DISCREPANCY: motivation for change occurs when people perceive a discrepancy
between where they are and where they want to be. MI counsellors work to develop this
situation through helping clients examine the discrepancies between their current
behavior and future goals. When clients perceive that their current behaviours are not
leading toward some important future goal, they become more motivated to make
important life changes.
6) PLANNING: The planning stage can be the most important part of motivational
interviewing in terms of its ability to aid in a long-term recovery. Part of the planning
process is about developing the skills and knowledge so that clients can catch themselves
before they fall. Whether by using coping mechanisms when they have the urge to use or
knowing who to reach out to and how when things get difficult, the planning stage
decreases the chance that a patient will relapse. It is important that during this stage, the
therapist is able to use his or her expertise to help give advice and coping mechanisms
without undermining or reversing the client’s sense of empowerment. The patient must
be reminded about the motivation and self-worth they found throughout the previous
sessions.
OARS
OARS is a series of interpersonal communication skills that facilitate clear conversations and a
collaborative working relationship.
O: Asking Open questions refers to a technique which encourages patients to become more
involved in the conversation. Rather than asking “closed” or fact-gathering questions, patients
are inclined to elaborate on their answers and do most of the talking. The counselor is there to
listen and empathize with the patient, helping build a stronger relationship and a trusting,
comfortable atmosphere.
A: Affirming involves bringing attention to a client’s strengths. During this process, it is
important for the counselor to comment positively on their patient’s progress, efforts, attributes,
and the steps they have taken towards recovery rather than any shortcomings or stumbles they
have had along the way. This helps make sure that patients don’t feel the need to defend their
worth or their progress, and therefore they can be more open to self-examination and further goal
setting.
R: Reflecting can be done in 2 ways: simple reflections and complex reflections. Both involve a
counselor showing empathy and understanding to their client. Simple reflections are carried out
by reiterating something the client has said, either word for word or slightly rephrasing what has
been said. Complex reflections entail making skillful guess about something the client has
implied, but maybe hasn’t said aloud. Reflections are usually portrayed as statements rather than
questions, as it shows a deeper level of understanding in regard to the counselor’s patient.
Questions can sometime provoke more defensive response from patients, so when a therapist
gives input via statements it helps the patient see something they might not have before without
potentially offending them.
S: Summarizing allows the therapist to compile all of the information, concerns, and revelations
that a person has shared with them. When the patient is able to consider all of this together, it can
be easier for them to realize that they want to recover and get sober. Summaries are particularly
effective at helping a patient realize their own “change talk.” Change talk is a concept usually
initiated by a therapist trying to encourage a patient to change their ways and seek sobriety.
However, with MI, the patient is able to initiate their own change talk, making their desire to
recover even stronger.
FRAMES APPROACH
The FRAMES approach consists of six components designed to move patients toward self-
awareness and build confidence in their ability to change. This method can be incorporated into
screening, brief intervention, and referral to treatment (SBIRT) interactions. These components
are summarized in the acronym: Feedback, Responsibility, Advice, Menu of options, Empathy,
and Self-efficacy. When working with SUDs, providers should:
● Give clients personalized feedback from assessments so they understand how the severity of
their problem compares to others. This can include results from standardized screening or
assessment instruments. Feedback can influence motivation for treatment and promote
movement between stages of change.
● Empower clients to become involved in the change process by taking responsibility for
choices they make about their substance misuse and the effect on treatment initiation and
outcomes.
● Seek permission to offer directive or educational advice in the form of suggestions and/or
potential activities or processes that promote positive change. Clients can then provide feedback
and ask for clarification about the provider’s suggestions. This approach requires patience and
careful timing.
● Present choices through a menu of options to promote client engagement and facilitate
treatment. These choices have been shown to enhance the therapeutic alliance, decrease dropout
rates, and improve outcomes (Van Horn et al., 2015).
● Demonstrate empathy by taking an active interest in understanding the perspective of the
client through the use of reflective listening (Miller & Rollnick, 2013). Provider empathy is a
moderately strong predictor of client treatment outcomes (Elliott et al., 2018). ● Assist with the
enhancement of self-efficacy by supporting the client, helping to review past successes,
identifying personal strengths, and building the client’s confidence in the ability to make positive
changes (Kadden & Litt, 2011). Considerable evidence points to self-efficacy as an important
factor in addiction treatment outcomes (Kadden & Litt, 2011; Kuerbis et al., 2013; Litt &
Kadden, 2015; Morgenstern et al., 2016).
MI is intended to work through its four main principles: (1) express empathy, (2) support self‐
efficacy, (3) roll with resistance, and (4) develop discrepancy. The third principle, rolling with
resistance, means that the counsellor does not fight client resistance, but "rolls with it."
Statements demonstrating resistance are not challenged. Instead the counsellor uses the client's
"momentum" to further explore the client's views. Lastly, motivation for change occurs when
people perceive a discrepancy between where they are and where they want to be. MI
counsellors work to develop this situation through helping clients examine the discrepancies
between their current behavior and future goals. When clients perceive that their current
behaviours are not leading toward some important future goal, they become more motivated to
make important life changes.
