Thad R. Leffingwell
Department of Psychology, Oklahoma State University, Stillwater, OK, USA
MI's technical and theoretical roots trace to the client‐centered counseling strategies popularized by Carl Rogers and classic social psychological theories of cognitive consistency (Festinger, 1962) and psychological reactance (Brehm, 1966). The first clinical application of the method that would come to be known as MI appeared in the research literature in 1988 in the form of the Drinker's Check‐up, which utilized nonjudgmental client‐centered listening skills while reviewing assessment feedback (Miller, Sovereign, & Krege, 1988). William Miller continued to develop the method, and, after developing a collaborative partnership with Stephen Rollnick, the first book fully describing the MI approach was published in 1991 (Miller & Rollnick, 1991).
For the first few decades of the development, investigation, and dissemination of MI, applications of the method were focused almost exclusively upon intervening with misuse of and addiction to psychoactive substances, including alcoholism and drug addiction. Indeed, the subtitle of the first book was Preparing People to Change Addictive Behaviors (Miller & Rollnick, 1991). MI targets ambivalence in the behavior change process, which often manifests as resistance to change and is common among people struggling with addictions. After the initial empirical success and accelerating dissemination of MI among substance use professionals, others began applying and investigating MI in other contexts with other target behaviors and populations including primary healthcare (Rollnick, Miller, & Butler, 2008), health promotion (Resnicow & Rollnick, 2011), and mental health (Arkowitz & Westra, 2004), with both adults and adolescents (Cushing, Jensen, Miller, & Leffingwell, 2014; Jensen et al., 2011). The growing recognition of the wider applicability of the MI approach was reflected in the second book, subtitled Preparing People for Change (Miller & Rollnick, 2002). Today MI is recognized as a broadly useful tool for helping me make a broad range of behavior changes, especially when ambivalence or resistance to change is present.
It is a well‐known problem that habits are difficult to change even when the status quo is maladaptive or unhealthy and that people often resist professional attempts to assist with change. According to the transtheoretical model, people may be in the pre‐action stages of precontemplation (not even thinking about change) or contemplation (acknowledging need or desire to change, but not now or soon) for months or years (Prochaska, DiClemente, & Norcross, 1992). The contemplation stage is characterized by ambivalence about change—a part of the person sees the need or wants the change, but another part prefers and defends the status quo. The preference for the status quo can be driven by many factors including, for example, lacking confidence about the likely success of change attempts, valuing other priorities more highly right now, or favoring immediate benefits more than long‐term payoffs that are subject to delay or probability discounting (Bickel, Johnson, Koffarnus, MacKillop, & Murphy, 2014). From the MI perspective, these individuals are viewed as stuck in ambivalence, and the goal of the MI conversation is to help patients get unstuck and move toward attempting and sustaining necessary behavior changes.
In conversations about a behavior change, patient language basically takes one of two forms—change talk or sustain talk (referred to as “resistance” in earlier versions of MI). Change talk is defined as any expressions that favor or encourage change, including concerns about the status quo, fears about the future if the behavior does not change, ideas about how change might be accomplished, or intentions to change. Sustain talk, on the other hand, is defined as any expressions from the patient that argue for or defend the status quo, including descriptions of advantages or benefits of the status quo, denigration or barriers to change, or hopelessness about change.
The MI approach takes several important positions about patient language in conversations about behavior change. First, the MI model posits that the patient's language is much more influential on subsequent behavior than the provider's language. As a result, MI de‐emphasizes motivational strategies that are more provider centered such as education, warning of dangers, direct persuasion, or professional advice. Second, the MI model suggests patients are better persuaded by their own language and that the more they hear themselves expressing change talk in the conversation (and, as a result, less sustain talk), the more subsequent attempts at change are to occur. Miller and Rose (2009) proposed a theory of MI that proposes that when change talk grows and sustain talk falls away during an MI conversation, the patient is more likely to experience and/or express a sense of commitment to change that is supported by a sense of intrinsic motivation, and it is this inner psychological experience that sets the stage for subsequent behavior change. As a result, the primary goal during an MI conversation is to increase the frequency and/or intensity of change talk and decrease the frequency and/or intensity of sustain talk as a way of building intrinsic motivation and evoking commitment to change.
MI has been described as have both a “style and spirit” as well as a set of proscribed conversational strategies and recommended techniques. The style and spirit can be thought of as the attitude, worldview, or stance of the MI provider. Rather than being about what the MI provider is to “do,” the MI style and spirit is about how the MI provider should “be” during the conversation. The style and spirit have been described as the music or melody of MI, giving it pace and feeling, when used with the “lyrics” of the skills and strategies.
In the original formulations of MI (Miller & Rollnick, 1991, 2002), the spirit of MI was described as consisting of three main characteristics. First, MI should have a spirit of collaboration. The interaction between provider and patient should have a sharing of power, as opposed to a “one up, one down” character. The provider is to avoid taking on a role as expert or authority and instead try to develop a sense of equal partnership in exploring the topic of behavior change. Second, MI should be evocative. In MI, the most valued words in the conversation at the patient's own. If change is to happen, it is mostly likely to be as a result of the patient being persuaded by his or her own words, rather than succumbing to the arguments or persuasion of the provider. For this reason, it is important for the MI provider to act in ways that encourage and evoke the patient's side of the conversation. Finally, MI should be autonomy supportive. Ideally, in an MI conversation, the patient would experience an expansion of their sense of personal choice and autonomy, rather than experiencing attempts to control or limit choices (e.g., “you must…”). This aspect of MI reduces the influence of psychological reactance and improves the chances that the patient may overcome ambivalence and reactance and choose to make necessary changes.
The latest description of the MI technique (Miller & Rollnick, 2013) expanded a bit upon these basic aspects of the spirit of MI. The aspects of collaborative partnership and evocation remain, but autonomy support has been subsumed under a broader concept of acceptance. Autonomy support is viewed as one facet of acceptance, but the concept also includes a fundamental belief in the absolute worth of the individual, accurate empathy, and affirmation, or actively seeking out and elevate an individual's strengths. Finally, the third edition also adds compassion as an important aspect of the essential spirit of MI. Compassion refers to the intentional application of MI in the service of what is best for the patient, not the provider.
MI also includes a number of proscribed or recommended strategies for the competent practice of MI. These strategies represent the “microskills” by which the spirit of MI is translated into practice and are in service of enacting the spirit. The skills can be reliably coded, and more consistent use of the strategies in the context of MI conversations has been found to lead to more favorable outcomes (Magill et al., 2014; Moyers, Martin, Manuel, Hendrickson, & Miller, 2005).
The most fundamental skills of the MI conversation involve the strategic use of active listening skills. In MI, the provider is expected to utilize evocative strategies such as open‐ended questions, accurate reflections, and frequent summaries. MI de‐emphasizes the value of provider‐centered language of advice, education, or persuasion. The goal of the MI provider is to strategically and intentionally apply the skills of active listening to evoke and grow change talk and quiet sustain talk from the patient.
One highly effective MI strategy is the use scaled questions, or what are sometimes referred to as readiness rulers (Rollnick et al., 2008). MI providers may wish to assess readiness to change, confidence in change, or the important of change using a 0–10 scale. For example, “How ready would you estimate you are to quit smoking today, from zero to ten, with zero being ‘no interest at all’ and ten being ‘totally committed?’” The answers provided to such questions provide a very useful and quick assessment of the constructs of interest, but they are especially valuable if follow‐up questions are asked. For example, if patient were to respond to the example question with “four,” a useful follow‐up question might be something like “Why did you choose four, and not zero?” The answers to that question would almost certainly take the form of change talk. This strategy reliably evokes valuable change talk into the conversation. Scaled questions are often recommended in brief and specialized adaptations of MI like the “5 A's” and Screening, Brief Intervention, and Referral to Treatment (SBIRT) models, discussed below.
Two other broad MI strategies are essential to the competent practice of MI—rolling with resistance and developing discrepancies. Argumentation and confrontation in response to patient resistance are seen as counterproductive, largely because they tend to increase frequency and intensity of sustain talk. Rolling with resistance is an alternative strategy for responding that is intended to quiet sustain talk or, ideally, evoke the “other side of the coin” of change talk. MI includes many specific strategies rolling with resistance including the use of reflective listening strategies but also reframing or emphasizing choice and autonomy, among others.
Developing discrepancy is based upon theories of cognitive consistency and dissonance that posit that people strive for consistency between attitudes and actions (Festinger, 1962). When individuals are confronted with inconsistency, they experience a sense of dissonance that is uncomfortable, and they are thus motivated to act in such a way to reduce the discrepancy. When one's behavior is experienced as inconsistent with an attitude or belief that is highly valued, that individual may be expected to change their behavior to better fit, or “square,” with the attitude or belief. For this reason, the MI practitioner is constantly listening for ways that the status quo may be inconsistent with a value, goal, or aspect of self‐image of the patient. If such discrepancies are found and made salient, they may help move the patient in the direction of change. For example, an MI provider working with a smoker may at some point in the conversation say something to the patient like “you strike me as the kind of person who really values your independence, but at the same time you find yourself quite dependent on those cigarettes. In a sense, you don't choose them – they choose you.”
In the latest iteration of MI (Miller & Rollnick, 2013), a new concept was introduced of the four processes of MI. The four processes essentially define the beginning, middle, and end of an MI encounter, though they do not necessarily always proceed in a linear fashion. The four processes are engaging, focusing, evoking, and planning. Engaging is the first step into an MI conversation and involves establishing a rapport and relationship as a foundation for proceeding. Focusing is a process of narrowing the agenda for the conversation onto one, or a few, important target behaviors for the conversation. Evoking is the process that most providers may recognize as the “meat” of the MI conversation. It involves an intentional conversation about the target behavior, with a focus of evoking and growing change talk and minimizing resistance. The final process of planning involves the transition from whether change should or will occur (the primary focus of MI) into how a change may occur. This process might involve plans to simply revisit the issue if now is not the right time to change, or might involve a detailed plan for change including the use of professional assistance.
MI has emerged and developed in the age of evidence‐based practice. As a result, MI has been rigorously studied from its very outset, and today there have been hundreds of randomized clinical trials and several meta‐analyses evaluating the efficacy of MI for a broad range of outcomes and populations. In general, the data overwhelmingly support the conclusion that MI does have a reliable effect on a broad range of target behaviors including alcohol misuse (Burke, Arkowitz, & Menchola, 2003), tobacco dependence (Heckman, Egleston, & Hoffmann, 2010), obesity (Armstrong et al., 2011), and gambling (Yakovenko, Quigley, Hemmelgarn, Hodgins, & Ronksley, 2015) and as an adjunct for treatment of psychological disorders (Arkowitz, Miller, & Rollnick, 2015), among both adults and adolescents (Cushing et al., 2014; Jensen et al., 2011). The effect sizes for MI interventions are typically small to moderate, but that may not be surprising given that the durations of the interventions studied are often quite brief, typically ranging from only a few minutes to two brief sessions. As a result, the cost‐effectiveness of MI interventions is quite strong.
MI is a complicated clinical intervention approach for which training is necessary. The available evidence suggests that a broad array of health professionals, including both medical providers and social service providers, can be trained to effectively implement MI competently (Madson, Loignon, & Lane, 2009). However, in order for improvements toward the competent practice of MI to be maintained, a single training or workshop is unlikely to be sufficient. Sustained competent practice of MI typically requires intensive training with performance feedback followed by several months of ongoing coaching and supervision (Schwalbe, Oh, & Zweben, 2014).
MI proper is a principle‐driven approach that relies upon the expertise of the provider to identify appropriate targets for MI and to weave MI interventions together with other strategies that suit the needs of the particular client or problem at the moment. However, due to the demands of clinical trials to have replicable interventions and the demands of real‐world settings to have more easily disseminable models for specific target behaviors (e.g., tobacco use) or settings (e.g., hospital emergency rooms), there have been a number of efforts to develop specific MI‐based treatment and intervention models.
One example of an MI‐based treatment is motivational enhancement therapy (MET), a treatment designed and tested initially as part of Project MATCH, a large multisite clinical trial of interventions for alcohol abuse and dependence (Miller, Zweben, DiClemente, & Rychtarik, 1992). MET was a brief intervention consisting of four treatment sessions and utilized the basic principles of MI at the time. Like the original Drinker's Check‐up (Miller et al., 1988) and many early trials of MI, the MI conversation occurred in the context of reviewing the results of a comprehensive clinical assessment, especially in the first two sessions. In the last two sessions, spaced weeks apart, the therapist would use MI principles to encourage motivation and progress.
Other adaptations of MI have attempted to create simplified, targeted intervention models that could be more easily disseminated to a variety of providers. For example, the Surgeon General's influential document treating tobacco dependence promoted a “5 A's” model of brief intervention designed to be implemented by a variety of healthcare providers at every encounter with patients who use tobacco (Tobacco Use and Dependence Guideline Panel, 2008). The five A's are as follows: (a) assess every patient for tobacco use and for those who are current users proceed to (b) advise quitting with brief, personalized advice; (c) assess for readiness to make a quit attempt and motivate those who are not currently ready; (d) assist with a quit attempt by offering guidance, prescriptions, or referrals; and (e) arrange for follow‐up at subsequent visits. The recommendations for assessing readiness and motivated unmotivated patients essentially describe the practice of MI. A similar brief intervention model that incorporates MI is SBIRT (Babor et al., 2007). SBIRT is a model for brief intervention designed initially for use in busy hospital emergency departments to address patients for who alcohol or drug misuse may have contributed to their illness or injury. The brief intervention component of SBIRT is essentially MI.
MI is a broadly applicable and essential evidence‐based approach to working with patients to overcome resistance and move toward healthy behavior changes. The approach can be learned and applied by many different types of providers and is applicable to many clinical problems and populations.
Thad R. Leffingwell is a clinical health psychologist and is currently a professor and head of the Department of Psychology in the College of Arts and Sciences at Oklahoma State University. His research has explored how people change health risk behaviors and how providers can interact with patients to encourage behavior change more effectively. He is a member of the Motivational Interviewing Network of Trainers and has providing training in MI to thousands of providers over the last 20 years.