Summary:
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Motivational Interviewing (MI) is a therapeutic approach where clients, rather than clinicians, articulate their own reasons for change, fostering self-motivation.
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MI balances being directional but non-directive, allowing clients to explore and discover their own paths to behavioural change through techniques like open-ended questions and reflective listening.
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The core principles of MI – partnership, acceptance, compassion, and empowerment – help psychologists build trust and guide clients through their ambivalence toward change.
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MI can be effectively combined with other therapeutic techniques, such as CBT or compassion-focused therapy, to support clients experiencing mixed feelings about treatment.
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The key to MI’s success lies in avoiding the ‘fixing reflex,’ allowing clients to take ownership of their decisions without feeling pressured.
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Register for our CPD Approved eLearning course, Know your therapies: Motivational Interviewing (MI) for a foundational introduction to MI.
A Motivational Interviewing (MI) expert shares the foundational elements of this therapeutic technique and outlines how psychologists’ clients might benefit from this approach.
The work of a psychologist is often based around supporting people to manage or better understand change in their lives. They might want to change their relationships, their habits, their thinking styles or perhaps their behaviours.
"The problem is that change is difficult. People have mixed feelings about it and often feel ambivalent about change. They'll have a whole bunch of arguments in their mind against change, but they'll also have some arguments for change as well," says Dr Stan Steindl, a clinical psychologist and researcher who specialises in motivational interviewing and compassion-focused therapy.
When a psychologist tries to persuade someone to change and, therefore, slips into a directive or solutions-focussed approach, the client's arguments against change can grow stronger, he says. This is because it's in our nature to believe the things we tell ourselves over the things others try to tell us, which is why techniques such as motivational interviewing (MI) can be so effective.
What is Motivational Interviewing?
"Motivational Interviewing (MI) is about working out how we can have conversations where the client, rather than the clinician, practitioner or therapist, is the one making the arguments for change.
"It's not directive but nor is it wholly non-directive," he says. "It's actually directional. We try to create a direction, but the client will be a big part of determining what that direction is."
By using open-questions, reflective listening, affirmations, reflections and summaries, psychologists who utilise MI can help clients to come to their own conclusions about behavioural or mindset changes that might have a positive benefit on their life, such as choosing to stop drinking, giving up gambling or recovering from an eating disorder, to name just a few examples.
There are a variety of principles of MI that psychologists and health practitioners utilise – such as leading with a sense of curiosity and exploration, expressing empathy and 'rolling with resistance' – and Dr Steindl highlights four in particular: partnership, acceptance, compassion and empowerment.
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Partnership: Rather than positioning themselves as an authority, the psychologist works alongside the client as a co-collaborator. This sense of equality helps to foster an environment where the client feels respected and more open to exploring their own motivations for change.
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Acceptance: This means recognising the client’s autonomy and acknowledging that they are the ultimate decision-maker in their own life. This involves being non-judgmental and valuing the client’s strengths and experiences, which can help to reduce defensiveness and build rapport.
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Compassion: The psychologist demonstrates genuine care and concern for the client's wellbeing, ensuring that the client feels understood and supported. Compassionate listening can help build trust, making it easier for the client to open up about their thoughts and feelings.
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Empowerment: This involves helping clients recognise their own capabilities and strengths, enabling them to take ownership of their decisions and actions. By focusing on the client’s ability to make changes, the psychologist reinforces their sense of self-efficacy.
By integrating these principles into the therapeutic relationship, psychologists create a safe and supportive space where clients feel empowered to explore their ambivalence, articulate their own reasons for change and take ownership of their path forward.
MI as a complementary tool
As well as being an effective technique in its own right, Dr Steindl describes MI as a great tool to use in conjunction with other therapeutic techniques.
He shares an example of a client who is experiencing a social phobia to illustrate this.
"Say you're starting to develop a graduated exposure plan with the person… but then their anxiety arises at the thought of it. Even though they might know it's going to help them, they're really struggling.
"[The psychologist might suggest] doing CBT or a kind of exposure hierarchy exercise, but perhaps the client has mixed feelings about it. In that instance, we might bring some MI into that moment to develop a conversation around going ahead with that treatment or doing the homework, and we might even get to a commitment.
"Whenever a client is feeling two ways about a certain type of therapy MI can be a nice adjunct [approach].
"I bring MI into a lot of compassion-focused therapy where people have certain fears, blockers and resistances to self-compassion – they might think it's self-indulgent or too much like self-pity, but then they might also know they need to practise self-care.
"It's something all psychologists can have in their toolkit when those difficult or ambivalent situations arise."
Putting it into action
At its crux, MI is about listening well and gradually exploring all sides of the situation with the client, says Dr Steindl.
"We will accept and validate the arguments against change – we don't want to invalidate that – but we will also gently guide people towards the arguments for change and help the person elaborate on that."
This looks like helping people to navigate different types of talk, he says. The first being 'sustain talk'.
This is when clients express reasons for not changing and defending their current behaviour or situation. It reflects their ambivalence or resistance to change.
In MI, rather than challenging or dismissing these thoughts, the psychologist accepts and validates them, showing empathy and understanding for the client's perspective. This approach helps the client feel heard and reduces defensiveness.
The psychologist gently guides the conversation towards ‘change talk,’ where the client starts to articulate reasons for wanting change, setting the stage for exploring possible solutions.
- Example phrases:
- "I’ve noticed things could be better if I made some changes."
- "It might be worth trying, even if it’s difficult."
- "If I could improve this, it would help in other areas of my life."
A good way to facilitate change talk is to utilise the Desire, Reason, Need and Ability framework, says Dr Steindl.
To illustrate this in action, he uses the example of a client who is coming to a psychologist to seek support with their excessive alcohol consumption.
Desire for change: "We might start by saying, 'What would you like to change about your drinking?' or 'If you were to make a change, what would you want it to be?' So it's about using language such as 'like', 'want' and 'preference'.
"This helps you identify a focus for the conversation," he says.
Reason for change: "Then your next question might be around the best reasons for change. You get them to talk about the benefits and advantages of change, or you might explore the cost of not changing. You could ask, 'What would be at stake if you didn't change?'
Need for change: Next, you might ask about what makes the change important.
"You could ask questions like, 'How does your current behaviour fit with your values? How important is it for you to move closer to those values by changing your behaviour?
Ability to change: Then you talk about their ability to enact change.
"Ask, 'What would be helpful for you? What might some of the solutions be?' We're always trying to stay evocative."
The key skill to bring this all together is reflection, he adds.
"If MI was a car then reflection is its engine. Reflective listening, trying to deepen the conversation through complex reflections, reflecting feeling, reflecting meaning, using different types of reflections to help with that directional piece, that's all really important."
Occasionally, psychologists practising MI might also affirm clients' strengths and positive qualities, and summarise what's discovered in the 'change talk' phase.
"We want people to hear themselves speak about the arguments for change and then reflect that back to them. We hold up little mirrors, which are the reflections, and every now and then we hold up a big mirror, which are those summaries.
"Ultimately, we'll then get to commitment language. So we accept and validate the sustain talk. We guide towards the change talk, and evoke and elaborate there, and then at some point we might arrive at a commitment."
Avoid the 'fixing reflex'
While commitments are an important step in the right direction, Dr Steindl says MI is not about 'getting' someone to a certain outcome. It's about helping them explore and better understand their ambivalence.
"One of the first things is for therapists to get out of their own way," he says. "Our default can often be: 'If I give enough research examples' or 'If I deliver a logical argument, that will convince them'. But we run the risk of coming up with all these logical arguments [for a certain treatment] and then the client comes up with their own logical arguments against that treatment."
In MI, this is referred to as 'fixing reflex'.
"The reality is, psychologists get into these jobs because they want to help people. We're people people, and oftentimes our 'fixing reflex' is an enthusiastic response because we can see where a solution lies for a person and we don't want them to suffer anymore."
It can also stem from an anxious place, he adds, such as if you start to feel anxious for your client.
"Or sometimes it might me anxiety arising out of the system that we're working in – we're only allowed a specific amount of time or sessions, and we have to see all these different people and get certain outcomes for them. That can increase our fixing reflex."
But this kind of thinking goes against the key element of MI, which is that the client, not the psychologist, needs to make the arguments for change.
"Whenever possible, try to stay evocative. And, the reality is, clients will often come up with the best solutions anyway."
This isn't to say there's no space for advice giving in MI, he adds. You just need to be careful about how you frame it.
"When you do come up with a really great solution… see if you can turn it into a question. Ask not tell.
"You might say something like, 'Okay, you feel like something's got to give. The drinking has got you in a bit of trouble at work, your wife is quite concerned about it and the GP has told you that some of the numbers are up in your liver functions test. You feel like you need to do something about the drinking. If you were going to make a change, how would you go about it? What might be a first step? What's a small step you could take, perhaps across this coming week, where you could begin a process towards change?
"You're holding the mirror up, you're offering back the change talk and then you're inviting a solution," he says.
It's also important to seek permission before you offer advice, he adds.
"Ask, 'Would you mind if I offered up a few ideas of things that have worked well for people before?' You're demonstrating that it's their choice and that it's a partnership."
Once you've received permission to offer solutions, then you can offer a "menu of options".
"And then you might say, 'Well, some people, some people start by reducing their drinking a little bit on a daily basis for the first week. Some people try having alcohol-free days. Some people feel they have to abstain from drinking. That feels easiest. What do you make of all of that?'
"So we're still being evocative in a way, but they still get to choose."
Motivational Interviewing offers psychologists a powerful framework for guiding clients through the often challenging process of change. By fostering collaboration, empathy and empowerment, MI enables clients to explore their ambivalence without pressure, leading to more sustainable, self-driven change.
Learn more about the nature of Motivational Interviewing (MI) and how and when it might be effectively used in our new eLearning course.
You can also download the APS Motivational Interviewing practice guide here.