Motivational Interviewing: How It Works & What To Expect

Core Concepts of Motivational Interviewing

There are two main concepts that apply to all motivational interviewing practices. The first is that change should be viewed as a process that goes through many stages. The second is the importance of the alliance between the counselor and the client.

Stages of Change in Motivational Interviewing

Inherent to motivational interviewing is the idea that change is a process. That process begins when a person becomes aware of the need to change and continues even after the change has been made. Because people may come into counseling at different stages in the change process, a central concept that guides motivational interviewing counselors is “meeting clients where they are”, or individualizing treatment to match the stage of change each client is in.

The five stages of change are:

1. Precontemplation: a person has not seriously considered or committed to the idea of change and may lack awareness that change needs to occur.
2. Contemplation: a person becomes aware that there is a need to change and is considering the idea but not ready to act.
3. Preparation: a person has made the decision to change and has set a date in the near future to begin the process. They may have also done some planning or preparation in this stage.
4. Action: when the change occurs, all the way from when a person starts the change to when they have completed the change (reached their goal).
5. Maintenance: after a goal has been reached. The focus now is on maintaining the change, avoiding pitfalls where they could slide back into the old behavior.

A sixth stage of change, Relapse, is sometimes added. While not a part of the original model, relapse, or a return to the old behavior, recognizes that in many cases, the change process is not linear, but occurs in a cycle that may include a temporary return to the old behavior. The sixth stage of change normalizes relapse and provides support in moving forward to reinitiate the change process.

The stages of change were developed separately from Motivational interviewing but have since become a core part of the model.²

The Counselor-Client Relationship in Motivational Interviewing

While most of the effort needs to be made by clients, motivational interviewing counselors also have a role to play in a client’s change process. Motivational interviewing places an emphasis on the relationship developed between the counselor and client. Often likened to a coaching relationship, the counselor acts as a guide and a support throughout the client’s process of change.

This focus on the alliance, or relationship, between the counselor and client comes from another type of counseling theory called Person-Centered Therapy. The emphasis on the therapeutic relationship is echoed in motivational interviewing, with 5 main principles guiding how this relationship is built and maintained.³

The five principles guiding motivational interviewing counselors are:

1. Expressing Empathy

The first task of a motivational interviewing counselor is to express empathy (nonjudgment and understanding) to the client, using specific listening skills outlined in Person-centered Therapy. This requires the counselor to both understand the client’s point of view and communicate this understanding to them.

2. Avoiding Arguments

The second task of a motivational interviewing counselor is to avoid trying to convince the client that their behavior is a problem or that they need to change, as these conflicts tend to be unproductive and can harm the relationship.

3. Developing Discrepancy

The third task of a motivational interviewing counselor is to help the client identify ways that their current behavior is discrepant, or in conflict with, what they want, need, or value. While uncomfortable, discrepancy is important because it often motivates change.

4. Rolling with Resistance

The fourth task of a motivational interviewing counselor is to “roll with resistance”, or to avoid getting caught up in conversations or conflicts about the client’s resistance to change. While resistance is seen as natural, counselors need to find creative ways to continue conversations about change in more productive ways without using confrontation.

5. Supporting Self-Efficacy

The final task of a motivational interviewing counselor is to support an increase in the client’s self-efficacy, or the client’s confidence in their ability to change. This is done by highlighting the client’s skills, strengths, and past successes.

Motivational interviewing counselors believe that the more a person talks about change, the more likely they are to change. They believe “change talk” is an important way that a client moves through the stages of change, eventually resulting in actual behavior change. By having pointed conversations about change and providing support and empathy, motivational interviewing counselors help build a client’s motivation and commitment to change.

Person-centered therapy was developed by a psychologist named Carl Rogers in the 1940’s. Rogers claimed that benefits in therapy were almost exclusively dependent on the strength of the rapport, or relationship, that the counselor was able to develop with the client.

What Motivational Interviewing Can Help With

Motivational interviewing is an approach that can be used to support any kind of behavior change. Research supports its use in both health and mental health care settings. Motivational interviewing was originally developed as a model to help clients overcome addiction, and this continues to be its most common application in mental health settings. It is used to treat a variety of addictive disorders including drug, alcohol and tobacco addiction and behavioral addictions like gambling.

In health care settings, doctors, nurses, and other healthcare workers are sometimes trained in motivational interviewing to support their patients in making certain lifestyle changes. Because most health issues involve lifestyle factors (ie: smoking, diet, exercise, etc), motivational interviewing can be useful to doctors and health care workers. In medical settings, motivational interviewing has been used to promote weight loss, pain management, oral health, smoking cessation, and disease management.⁴

Common Motivational Interviewing Techniques

Not all conversations about change are helpful. In fact, many of the ways people talk about change could reduce a person’s motivation for change. For this reason, most of the skills used by motivational interviewing counselors are skills to direct and redirect conversations, ensuring they are productive.

Productive conversations about change vary, but often focus on:

• Ways that the current behavior is both working and not working for the person
• Aspects of the behavior that conflict with a person’s larger goals, morals or values
• Consequences that might occur if the person continues the behavior and does not change
• Differences and benefits that may occur if the client does make changes
• Internal or external motivators for change
• Internal and external supports and resources that could help in the change process
• Lessons or skills learned from previous change efforts that could be useful
• Ways to break big goals down into smaller steps
• Ways of being held accountable for making changes
• Ways to overcome internal and external barriers to change
• Specific plans or preparations that need to be made before starting the change
• Ways of rewarding progress along the way
• Ways to get back on track with change in case of setbacks or relapses

Motivational Interviewing Exercises

In addition to helping people talk about change in productive ways, motivational interviewing counselors may also use specific activities and exercises. These activities and exercises are used to assess a client’s stage of change or to build motivation or commitment to change.

These exercises may include:

• Agenda mapping, which involves setting an agenda for sessions that help to structure and guide the conversation
• A pros/cons list that details benefits and drawbacks of making a change and/or not making a change
• Listing both short- and long-term rewards and consequences of a specific behavior
• Values inventories that are intended to help identify a person’s core values (what matters most to them)
• Scales that ask the client to rate their degree of readiness to change or confidence in their ability to change using a scale of 1-10, with 10 usually representing the highest levels

Motivational Interviewing Questions & OARS

Motivational interviewing counselors use specific conversational and listening techniques called OARS. OARS is an acronym stands for open ended questions, affirmation, reflections. These motivational questions and conversation skills help facilitate productive conversations about change.

Examples of motivational interviewing questions clients may be asked include:

• What consequences or problems have made you feel that change is necessary?
• If change is not necessary now, what circumstances would change that?
• What are you afraid might happen if you do not make a change?
• What about your life would be better if you did make a change?
• How would people you love respond if you made this change?
• How have you gone about making other changes in the past?

Developing the Change Plan

The change plan is a comprehensive plan created in session that details the person’s goal to change, motivations for change, and steps and strategies to change. The plan is a living document, consistently revisited and updated to reflect the client’s process and progress towards their goals. One of the first steps in developing the change plan is goal setting.

All goals are not created equal. In motivational interviewing, the “right” goals are SMART goals. SMART is an acronym that outlines 5 criteria that goals should meet.

SMART goals are:

Specific: Goals should outline specific actions rather than general outcomes
Example: Setting a goal to go running instead of a goal to “exercise”

Measurable: The actions or changes the person is making should be made measurable
Example: Setting a goal to run three times per week for 30 minutes vs to exercise “more”

Attainable: The actions or changes should be ones that are realistic and possible to attain
Example: If the person has never run before in their lives, a more realistic goal might be to begin by either walking or jogging three times a week for 30 minutes

Relevant: The change should be one that is relevant to what is motivating the change
Example: Jogging three times a week would be relevant if the motivation comes from a need to improve fitness or lose weight, but less relevant if the goal was to reduce stress

Time-bound: A target date/timeframe is outlined to specify when the change will occur
Example: Jogging three times per week for 30 minutes for the next 30 days

Once a SMART goal is identified, other aspects of the change plan will be created. These might include:

• Motivators: reasons why the person wants to make the change
• Specific steps in the process of making the change
• Ways progress will be measured throughout the process of meeting the goal
• Potential barriers that could complicate the plan or the ability to reach the goal
• Skills, support people, or other resources they will utilize to reach the goal
• Target date to achieve the goal and date to review the progress

Motivational Interviewing Examples

Motivational interviewing can be used to support people in making a variety of lifestyle changes. One of the more common applications of this approach is within the field of substance abuse treatment. If a person struggling with a substance use disorder wanted to receive motivational interviewing counseling, they would likely be receiving individual therapy from a trained counselor or addiction specialist. This therapist would have completed training in motivational interviewing from a MINT certified trainer.

Treatment is often provided in outpatient office settings and is typically provided in hour-long sessions that can occur 1-3 times weekly. Less commonly, motivational interviewing may be provided in group substance abuse classes that could meet as frequently as 5 times per week. What is done in motivational interviewing sessions will vary, depending on the individual needs of the client and the stage of change they are in. At each stage of change, the client’s needs are different, and the approach of the counselor will be different.⁵

Precontemplation Stage

A person who comes to substance abuse treatment in the precontemplation or contemplation stage is still using drugs or alcohol. For this person, early treatment might focus on building rapport and helping the client become more aware of the need to change. The counselor may carefully provide reflections or ask questions that would help the client become more aware of ways their current substance use might be causing problems or conflicting with their values. The purpose of these conversations is primarily to build motivation for change.

Preparation Stage

A person entering treatment in the preparation stage is also probably still using substances but has already made up their mind to cut back or stop. For this person, the focus of sessions would be on increasing commitment to change and on developing the change plan. The counselor would likely help the client set a date when the client will cut back or stop using (depending on their individual goal) and will help to outline specific steps, skills, and supports the client will use. The counselor might encourage the client to think about avoiding certain triggers (people, places, or situations the client associates with substance use) and what they will do to manage any cravings they have.

Action Stage

A person in the action stage of change has already stopped or cut back on their substance use and there needs tend to be accountability, support, and troubleshooting any barriers. The counselor might ask the client to talk about their progress, challenges, and what they have learned works/does not work for them. Using this feedback, sometimes there are changes that can be made to a person’s change plan that can strengthen it. Other times, reviewing the plan might lead to a revised goal; the person may have cut back on their drinking and now wants to stop altogether, for example. Over time, the counselor often encourages the client to identify other support people and skills outside of counseling in preparation for when treatment ends.

Maintenance Stage

Some clients recovering from drug or alcohol addiction seek counseling from a motivational interviewing specialist as a part of their maintenance plan. Those in the maintenance stage of change have already stopped or cut back on their use and are interested in staying on track with these changes. It is not uncommon for counseling sessions to be one way that people maintain sobriety, even after years of being clean and sober. In maintenance stages, counselors may help people continue to watch carefully for early signs of relapse or to manage difficult and stressful times, when people are more vulnerable to relapse.

Relapse

In instances where people are seeking treatment because they are in the relapse stage, motivational interviewing may focus on helping the client re-start the change process. Seasoned addiction counselors know that relapse is often a part of the recovery process and are equipped to helping clients practice acceptance and self-forgiveness after a relapse. Many addiction counselors believe that relapse can provide a rich learning opportunity, including more wisdom about what works and does not work for the person, and what red flags to watch out for.

How to Find Motivational Interviewing Treatment

Motivational interviewing counselors are those who have received training from a MINT certified trainer. Typically, these are offered in two-day training sessions that are attended by counselors, psychologists, and even doctors or health care workers. Finding trained counselors can be tricky, but a good starting place is an online therapist directory, which allows you to filter by individuals using this approach. In some cases, insurance may pay at least part of the costs for this type of counseling.

For those with health insurance, the best first step to finding a motivational interviewing counselor is typically through your insurance providers. Calling the number listed on the back of the card or using the insurance company’s online search tools will provide a list of in-network providers near you. Because not all counselors on the list will be trained in motivational interviewing, it may be important to call or email the provider directly to ask if they have received training in this approach. If not, you could ask them for recommendations of other professionals in your community that do offer this type of counseling. Many counselors have a network of professionals that they refer to and are happy to share this information free of charge.

What to Expect at the First Appointment

If you are entering treatment for a substance use or mental health condition, the first appointment is usually a clinical assessment which is conducted by a licensed counselor or psychologist. You will be asked to complete intake paperwork, similar to what you complete for a medical appointment. You will meet privately with a counselor and be asked a series of questions about you, your life, and any symptoms you are experiencing. This might include questions about your overall mental health, mood, and functioning and also questions about any substance use.

For those struggling with substance use, you can expect to be asked questions about your substance use now and in the past, including how much and how frequently you use. While this is sensitive information, being completely honest is important, and in almost all instances, this information is completely confidential.

At the end of the assessment, it is possible that you would receive a diagnosis of a mental health or substance use disorder, which will be reviewed with you. At this point, the counselor would review recommendations and options for treatment. While some are hesitant about being diagnosed, this is a part of your personal health information, which is protected by federal privacy laws. Also, having a diagnosis is required to receive any insurance reimbursement for future counseling sessions.

A motivational interviewing counselor will often ask preliminary questions about any changes you are hoping to make, and questions designed to assess what stage of change you are in. They might even do some work on developing a treatment plan with you. The majority of the first appointment, however, is typically reserved for the clinical assessment. Future sessions are generally more focused on using motivational interviewing techniques.

Is Motivational Interviewing Effective?

Motivational interviewing is considered an evidence-based practice because it has been proven to be effective. Research supports it as an effective method for a variety of both health and mental health issues. A 2005 meta-analysis of 72 research studies found that motivational interviewing had a clinically significant impact in three out of four of the studies. The research included only randomized control trials of motivational interviewing used to treat both physical and psychological conditions.¹

How is Motivational Interviewing Different from Other Treatments?

In some ways, motivational interviewing is similar to other counseling approaches. Most counseling approaches emphasize the use of person-centered skills that encourage trust and open communication between the client and counselor. Many counseling approaches also use goal setting and treatment planning to structure sessions and help clients reach their desired goals. The focus on behavior change is also found in many other counseling approaches.

What distinguishes motivational interviewing the most from other counseling approaches are the careful techniques that are used to help direct specific conversations about change. Motivational interviewing sessions tend to be almost exclusively focused on topics related to change, as opposed to other types of counseling which might explore other aspects of a client’s life and experience.

History of Motivational Interviewing

Motivational interviewing is a counseling and coaching approach first developed in the 1980’s by a psychologist named William Miller and later furthered in collaboration with another psychologist named Stephen Rollnick. Together, Miller and Rollnick published books and manuals on the approach, which began as an approach used in alcohol treatment.⁶

At the time when it was developed, the approach stood in stark contrast to methods being used in drug and alcohol treatment. During this time, addiction counselors widely used very direct and confrontational methods with clients with drug and alcohol problems. It was believed that this approach was necessary to eliminate denial and excuses and force people to understand the need to change.

This eventually paved the way for his theory that an empathetic, supportive, and non-confrontational approach may be more effective in treating people with drug or alcohol problems. Eventually, this evolved into the approach now known as motivational interviewing.