Motivational Interviewing

There are many reasons why people might want to make positive changes in their lives, but there are also many reasons why they might lack the motivation to do so. It could be overcoming substance abuse, adopting healthier eating, or breaking away from criminal behavior. But, putting external pressure on a person to make changes to their behavior, lifestyle, or attitudes is often ineffective; people need to have the motivation to change in order for change to occur. 

In motivational interviewing, practitioners engage with clients in a practical way to help them find and enhance their own intrinsic motivation for change.² This occurs in two stages: first, building motivation to change; and second, strengthening commitment to change. 

The central idea of MI is somewhat paradoxical: For people to be able to change, they first need to feel accepted as they are.¹ To put it plainly, feelings of acceptance boost self-esteem and help bolster the motivation to change. 

One of the main goals of MI is to overcome ambivalence, the conflicted state where individuals are stuck between wanting to change and not wanting to change.³ For example, an individual with serious health problems as a result of heavy drug abuse may have genuine concerns about the impact of using on their health, but continue to take drugs despite advice from their doctor. In these cases, the perceived short-term benefits take precedence over the perceived long-term gains. 

MI is based on a set of principles that emphasize the autonomy of the client and a collaborative therapeutic relationship in which the therapist is viewed as a facilitator rather than an expert or authority. This is known as the “spirit” of motivational interviewing and has four components: 

Collaboration: The practitioner and client work together as partners. The practitioner respects the client’s expertise in their own life and avoids an authoritative, confrontational, or prescriptive stance. 

Evocation: Rather than imposing reasons for change from the outside, MI aims to draw out and cultivate the client’s own motivations and resources for change.

Acceptance: Practitioners demonstrate an accepting attitude toward clients by valuing the inherent worth of every individual, practicing empathy, respecting and reinforcing the client’ capacity for self-direction, and affirming the client’s strengths and efforts. 

Compassion: Practitioners are conscious of their commitment to the well-being and best interests of the client—showing empathy and promoting judgment-free communication. 

The 4 stages of motivational interviewing 

MI is based on 4 distinct processes that provide a structured yet flexible framework for helping clients navigate the complexities of behavior change. These processes—engaging, focusing, evoking, and planning—are designed to enhance the effectiveness of MI by guiding the therapeutic conversation in a way that respects the client's autonomy and fosters intrinsic motivation. 

These processes are not strictly linear; they often overlap and can be revisited as needed throughout the course of MI. The engagement process, for example, typically comes first as the therapist and patient develop a rapport, but is also present throughout the conversation. If engagement is lost at any point, the therapist will stop moving forward and go back to the engaging process to re-engage the patient.⁴ 

Engaging: This is the foundational step where the therapist establishes a trusting and respectful relationship with the client. Engaging involves active listening, empathy, and understanding the client’s perspective without judgment.

Focusing: Once engagement is established, the therapist and client work together to identify and clarify the specific behaviors, issues, or changes that the client wants to address. This involves setting an agenda and agreeing on the direction for the conversation.

Evoking: In this process, the therapist helps the client explore their motivations, desires, and reasons for change. This involves eliciting the client’s own arguments for change and addressing their ambivalence.

Planning: After the client has expressed a clear motivation to change, the therapist assists in developing a concrete and actionable plan for making the change. This includes setting goals, discussing potential strategies, and identifying resources and support systems.

• Transtheoretical Model of Change: A psychological framework developed by James Prochaska and Carlo DiClemente that outlines the process and stages individuals go through when changing behavior.
• Person-centred approach: A therapeutic framework and philosophy developed by psychologist Carl Rogers that places the individual at the center of the care process. This approach emphasizes the importance of understanding and respecting each person’s unique experiences, values, and needs.
• Change talk: Verbal statements by the client revealing consideration of, motivation for, or commitment to change. Change talk reflects the client’s readiness to change and can be harnessed by the practitioner to facilitate the change process. 

MI was originally developed in the early 1980s by clinical psychologists William Miller and Stephen Rollnick to treat alcohol addiction.⁵ Previous approaches to treating substance abuse focused heavily on personality disorders and the idea that the patient was “sick” and incapable of understanding the depth of their addiction. However, there was little to no scientific evidence to support this view. MI, on the other hand, sought to transform approaches to addiction treatment by shifting the focus away from what was perceived as something “wrong” with the patient towards building the individual’s motivation for change. 

The clinical method of MI evolved from and built upon Carl Rogers’ person-centered approach to clinical science. Rogers, an American psychologist, committed his career to the scientific study of therapeutic processes and outcomes, particularly in defining and measuring treatment process variables and testing their relationship to client outcomes through recording, coding, and analyzing therapy sessions.⁶ His humanistic theories about people’s capacity for exercising free choice and self-determination heavily influenced the “spirit” of MI and the idea that individuals should be their own agents of change. 

At around the same time that Miller and Rollnick were developing MI, psychologists James Prochaska and Carlo DiClemente were also crafting their own model of change. The Transtheoretical Model (TTM)⁷ posits that individuals progress through six stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination. Miller and Rollnick’s treatment method provided an example of an intervention appropriate for clients who are not yet ready or motivated for change, corresponding to the first three stages of the TTM.⁸ As a result, MI is now regarded as an intervention that can facilitate movement through the stages of the TTM.⁹

Over the years, the scope of MI has expanded beyond its initial application to behavior change (increasing or decreasing a particular behavior) to encompass complex change that may or may not be linked to a specific behavior. An example of this is forgiveness, an issue that may cause individuals considerable anguish and suffering. The choice to forgive someone may not result in behavior change, especially if the forgiven person is no longer around, but can elicit a change that is more cognitive and affective in nature.⁹

Today, MI is applied across a range of fields beyond clinical psychology, including health care, rehabilitation, public health, social work, dentistry, corrections, coaching, and education. Despite its proliferation, MI still remains a popular approach for treating addiction; a 2016 survey by Traci Rieckmann, Amanda Abraham, and Brian Bride found that two thirds of U.S. addiction treatment programs reported using MI.¹⁰

William Miller: American clinical psychologist and an emeritus distinguished professor of psychology and psychiatry at the University of New Mexico who specializes in behavioral treatments for additions. With his colleague, Stephen Rollnick, Miller developed the principles of MI. 

Stephen Rollnick: British clinical psychologist and professor at Cardiff University’s School of Medicine. In addition to developing the fundamental principles of MI, Rollnick’s research focuses on promoting positive behavior change in patients. 

Carl Rogers: American psychologist regarded as one of the founders of humanistic psychology and renowned for his person-centered approach to clinical sciences. 

James Prochaska: American psychologist who co-developed the Transtheoretical Model of Behavior Change (TTM) and contributed a significant body of research to the field of health psychology. 

Carlo DiClemente: American psychologist who co-developed the Transtheoretical Model of Behavior Change (TTM) and specialized in motivation and behavior change with a variety of health and addictive behaviors. 

When it comes to mental health and behavior issues, research shows that MI can outweigh conventional educational treatment by up to 80%.¹¹ Telling an individual that they need to start or stop doing something will only lead to temporary compliance. MI, on the other hand, fosters intrinsic motivation which promotes sustainable and longer lasting behavior change. This, in turn, translates into greater engagement with, and adherence to, treatment, and a reduction in relapse risks. 

MI also comes top of the class when compared to other therapeutic approaches. A study conducted by Henny Westra, Michael Constantino, and Martin Antony, for example, looked at the difference in effectiveness between MI and cognitive-behavioral therapy (CBT) in treating anxiety disorder. In a randomized trial, they split participants into two groups, one of which received MI sessions while the other received CBT sessions. Over a 12-month period, twice as many participants dropped out of the CBT group compared to the MI group.¹²

In addition to fostering change, MI can also have a significant impact on confidence, both for the patient and the practitioner. For patients, MI’s focus on their autonomy and own decision-making processes leads to greater self-efficiency and empowerment. For practitioners, MI training can lead to greater confidence when speaking to patients about their condition, which improves job satisfaction.¹³

So far, we’ve painted quite a rosy picture of MI. However, as with all approaches and methodologies, MI has its challenges, the main one being ethics. Practitioners, including MI’s co-developer William Miller, have raised and explored concerns about the potential for MI to be used manipulatively.¹⁴ As Miller explains, problems around motivation arise when the practitioner perceives a issue and the client doesn’t not share this perception. In a worst-case scenario, practitioners might inadvertently or intentionally steer clients toward changes that align more with the practitioner’s values or goals rather than those of the client. Miller proposes a continuum of levels of readiness to change, and of therapeutic strategies ranging from passivity to coercion. Ideally, MI sits in the middle of these two extremes, seeking to evoke intrinsic motivation for change rather than coerce patients into making change. 

So how can we be sure that MI is practiced ethically? Well, through training and long-term coaching. However, concerns have also been raised about levels of MI training proficiency and a lack of ongoing training, supervision, and follow up in healthcare settings.¹⁵ As with any skill, practitioners’ MI abilities decline over time without post-training feedback and continued coaching.¹⁶ This can have a negative impact in a number of areas, such as weakening the therapeutic alliance between provider and patient, inconsistent application of MI techniques, and deviation from the ‘spirit’ and core principles.  

Cancer patients and survivors

The adverse effects of cancer diagnosis and treatment (such as fatigue, depression, pain, and social isolation) can have a significant impact on a patient’s motivation and ability to engage in recommended levels of healthy behaviors. The time when an initial diagnosis is given and treatment begins is what nutritional scientists Wendy Demark-Wahnefried and colleagues describe as a ‘teachable moment’ during which oncologists can advise and motivate patients to engage in behavior change.¹⁷ Unfortunately, this early stage is also when these adverse effects can have their maximum impact on an individual’s capacity to maintain or improve healthy behaviors. 

However, a large body of research suggests that MI can encourage patients to adopt or adhere to healthier habits and engage in physical activity, which can improve overall well-being and potentially enhance treatment outcomes.¹⁸ A systematic review of 15 studies using MI in cancer patients and survivors found that this method was particularly successfully for addressing lifestyle behaviors, such as diet, exercise, and smoking.¹⁹ More specifically, MI has been applied to ‘exercise oncology,’ a practice aimed at mitigating symptom burden and improving overall health during treatment through physical activity. Studies show that MI, combined with other motivational strategies such as a pedometer, print material, and emails, can have significant beneficial effects on the total physical activity of cancer patients.²⁰   

Organizational change

Although commonly associated with health behaviors, MI can be applied to a range of contexts in which change is desired. In organizations across the globe, change is seen as an important process necessary for enhancing employee engagement, driving innovation, increasing productivity, and improving customer or client satisfaction. However, change can also cause uncertainty and anxiety among employees, leading to resistance and ambivalence towards change initiatives. 

A study by change management consultant Conrado Grimolizzi-Jensen tested the effectiveness of MI in helping employees resolve ambivalent attitudes towards organizational change initiatives. In the experiment, 56 employees were split into experimental and control groups, with the former receiving three sessions of MI over a 30-day period (the control group received no sessions). Grimolizzi-Jension found that exposure to MI significantly increased readiness to change, as compared to the control group, ultimately resulting in more successful change initiatives.²¹

The COM-B Model for Behavior Change

There are various frameworks and models for helping us understand and promote behavior change. Choosing which one to use depends on the behavior change you’re trying to achieve. The COM-B model, which proposes three necessary components (capability, opportunity, motivation) for any behavior to occur, is part of the furniture in the world of behavioral science. This article explores what the COM-B model is, what it’s used for, and how it was developed. 

Active Listening

Another of Carl Rogers’ inventions, active listening is a common communication technique which has been applied in a range of scenarios. Like motivational interviewing, active listening appears in healthcare situations to improve patient communication. Learn more about the strategy in this article.  

1.     Miller, W. (n.d.) The Power of Acceptance. Psychwire [video]. https://psychwire.com/free-resources/motivational-interviewing

2.     Miller, W. (n.d.). Homepage. William Miller. https://williamrmiller.net

3.     Hall, K., Gibbie, T., & Lubman, D. I. (2012). Motivational interviewing techniques. Australian Family Physician, 41(9). 

4. State of Colorado. (n.d.). The 4 Processes of MI. State of Colorado Division of Criminal Justice. https://cdpsdocs.state.co.us/epic/epicwebsite/resources/mi_communities_of_practice/4_processes/4_processes.pdf

4.     Hartney, E. (2023, November 14). Understanding Motivational Interviewing. VerywellMind. https://www.verywellmind.com/what-is-motivational-interviewing-22378

5.     Miller, W. R., & Moyers, T. B. (2017). Motivational Interviewing and the Clinical Science of Carl Rogers. Journal of Consulting and Clinical Psychology, 85(8), 757-766. 

6.     Prochaska, J. O., & DiClemente, C. C. (1983). Stages and Processes of Self-Change of Smoking: Toward an Integrative Model of Change. Journal of Consulting and Clinical Psychology, 51(3), 390-395. 

7.     Miller, W. R. (2023). The evolution of motivational interviewing. Behavioural and Cognitive Psychotherapy, 51(6), 616-632. 

8.     Hoy, J., Natarajan, A., & Petra, M. M. (2016). Motivational Interviewing and the Transtheoretical Model of Change: Under-Explored Resources for Suicide Intervention. Community Mental Health Journal, 52(5), 559-567.  

9.     Miller, W. R. (2023). The evolution of motivational interviewing. Behavioural and Cognitive Psychotherapy, 51(6), 616-632. 

10.  Rieckmann, T. R., Abraham, A. J., & Bride, B. E. (2016). Implementation of Motivational Interviewing in Substance Use Disorder Treatment: Research Network Participation and Organizational Compatibility. Journal of Addiction Medicine, 10(6), 402-407. 

11.  Takemura, N. et al. (2023). Effectiveness of motivational strategies on physical activity behavior and associated outcomes in patients with cancer: A systematic review and meta-analysis. Worldviews on Evidence-Based Nursing, 21(3), 253-262.  

12.  Westra, H. A., Constantino, M. J., & Antony, M. M. (2016). Integrating motivational interviewing with cognitive-behavioral therapy for severe generalized anxiety disorder. An allegiance-controlled randomized clinical trial. Journal of Consulting and Clinical Psychology, 84(9), 768-782.  

13.  Stoffers, P. J., & Hatler, C. (2017). Journal of Nurses Professional Development, 33(4), 189-195. 

14.  Miller, W. R. (1994). Motivational Interviewing: III. On the Ethics of Motivational Intervention. Behavioural and Cognitive Psychotherapy, 22(2), 111-123. 

15.  Weisner, C., & Satre, D. D. (2016). A key challenge for motivational interviewing: training in clinical practice. Addiction, 111(7), 1154-1156. 

16.  Schwalbe, C. S., Oh, H. Y., & Zweben, A. (2014). Sustaining motivational interviewing: a meta-analysis of training studies. Addiction, 109, 1287-1294. 

17.  Demark-Wahnefried, W. et al. (2018). Weight management and physical activity throughout the cancer care continnum. CA Cancer J Clin., 68(3): 232. 

18.  Harkin, K. et al. (2023). The impact of motivational interviewing on behavioural change and health outcomes in cancer patients and survivors. A systematic review and meta-analysis. Maturitas, 170, 9-21. 

19.  Spencer, J. C., & Wheeler, S. B. (2016). A systematic review of Motivational Interviewing interventions in cancer patients and survivors. Patient Educ Couns., 99(7), 1099-1105. 

20.  Takemura, N. et al. (2023). Effectiveness of motivational strategies on physical activity behavior and associated outcomes in patients with cancer: A systematic review and meta-analysis. Worldviews on Evidence-Based Nursing, 21(3), 253-262.  

21.  Grimolizzi-Jensen, C. J. (2017). Organizational Change: Effect of Motivational Interviewing on Readiness to Change. Journal of Change Management, 18(1), 54-69.