James MacKillop, PhD
Peter Boris Centre for Addictions Research, Department of Psychiatry and Behavioural Neurosciences, McMaster University; Homewood Research Institute, Homewood Health Centre
Lauren VanderBroek-Stice, MS
Department of Psychology, University of Georgia
Catharine Munn, MD, MSc
Peter Boris Centre for Addictions Research, Department of Psychiatry and Behavioural Neurosciences, McMaster University; Student Wellness Centre, McMaster University
An ostensible truism for a person seeking psychological treatment is that he or she wants to get better. In turn, a corollary of this assumption is that when a mental health professional provides a way to understand the problem, and, particularly in behavioral and cognitive therapies, lays out a plan of action for addressing it, the client will vigorously embrace those steps needed to alleviate the existing distress. The reality, however, is that the course of psychological treatment is often far less simple and linear. Clients avoid prescribed intersession activities, do not complete homework, miss sessions, or voluntarily lapse into the distressing behaviors that were the impetus for treatment.
This work was partially supported by a grant from the Ontario Ministry of Training, Colleges, and Universities Mental Health Innovation Fund (James MacKillop and Catharine Munn). Dr. MacKillop is the holder of the Peter Boris Chair in Addictions Research, which partially supported his role.
One reason for suboptimal outcomes is that, fundamentally, behavior change is not easy. This is in part because seemingly dysfunctional behaviors are serving a function, typically keeping an experience that is even more undesirable than the manifest symptoms at bay. In other words, maladaptive behaviors often serve as transient, short-term solutions to problems that are ultimately exacerbated in a vicious cycle. Thus, an unhealthy behavioral homeostasis is achieved, and these functional/dysfunctional behaviors gain a persistent momentum that is challenging to change. This is compounded by the fact that clients may not commit to treatment out of ambivalence about addressing the presenting problem. Importantly, it is not ambivalence in the sense that they are indifferent to the outcome. Clients are ambivalent in the literal sense of being pulled in two directions: by a desire for change and by the inertia of existing behavioral patterns. The earliest forms of psychological treatment, starting with Freud, recognized the “neurotic paradox” that such ambivalence creates. Behavior therapists likewise recognized it as a challenge to the rational assumptions of learned behavior (Mowrer, 1948). Fundamentally, it is the question of why, if a maladaptive behavior leads to distress and the desire for change, does actual behavior change not naturally follow.
In the contemporary context, this inability to change can be understood as a problem of motivation. At a superficial level, client motivation is often assumed to be self-evident from the fact that treatment is being sought. Therapists inaccurately assume it to be a stable, unwavering trait. Instead, motivation for change is increasingly understood as a dynamic and fluctuating process, with a waxing and waning periodicity. Actively considering and cultivating motivation for change in psychological treatment is the focus of this chapter, which draws on the extensive body of work on motivational interviewing (MI; Miller & Rollnick, 2002, 2013), a therapeutic method for facilitating a client’s intrinsic motivation to change behavior. Regardless of treatment modality or form of psychopathology, motivation is a sine qua non of successful behavior change, and MI has been found to be a powerful intervention, both on its own and as a platform for other psychological interventions.
MI was originally developed in the treatment of addiction, for which ambivalence is arguably a hallmark of the disorder, but its reach far exceeds addictive disorders. This chapter will introduce some of the language and concepts of MI, but it should not be considered the equivalent of formal training. As Miller and Rollnick (2009) wisely and concisely noted, “MI is simple, but not easy” (p. 135), and there is evidence that learning MI requires more than superficial training (Barwick, Bennett, Johnson, McGowan, & Moore, 2012; Madson, Loignon, & Lane, 2009; Miller, Yahne, Moyers, Martinez, & Pirritano, 2004).
Motivational interviewing has its roots in William Miller’s research on alcohol-use disorders in the early 1980s, when it was found that clinician empathy was more predictive of treatment outcome than the active effects of behavioral treatment (Miller, Taylor, & West, 1980). This serendipitous finding led to subsequent explorations of how interpersonal processes and clinician style promote behavior change, and an initial description of motivational interviewing as an approach emphasizing empathetic, person-centered therapy that focuses on evoking and strengthening the client’s own arguments for change (Miller, 1983). Included in this approach was a deeper theoretical grounding that emphasized two major elements. The first was Rogers’s (1959) humanistic emphasis on the value of a positive and empathetic environment, in which clients can express feelings and explore issues without fear of judgment. The second included both Festinger’s (1957) idea that cognitive dissonance occurs when individuals perform an action that conflicts with a core belief or value and leads to motivation to restore consistency of actions and beliefs; and Bem’s (1967) self-perception theory that proposed people become more attached to attitudes that they verbalize and hear themselves defend. Reflecting these ideas, MI cultivates a strong client-clinician relationship characterized by high levels of empathy, and it draws attention to discrepancies between clients’ current circumstances and their values using a Socratic style that elicits the discrepancy from the clients in their own words (evoking, not telling). More concretely, MI combines an empathic therapeutic style with intentional selective reinforcement of client language that favors change (Miller & Rose, 2009).
This perspective differed dramatically from the dominant models of addiction treatment at the time. In the 1980s, the prevailing view of individuals with substance-use disorders was that many were in “denial” of their problems, an attribution that unfortunately persists and for which there is little evidence (Chiauzzi & Liljegren, 1993; MacKillop & Gray, 2014). Clinicians commonly sought to persuade clients to change and to argue against their resistance, often inadvertently provoking clients to defend the status quo. The MI perspective was qualitatively different, assuming instead that many afflicted individuals were aware of the need for change and possessed some degree of internal motivation to do so, an assumption that is robustly supported by client reports on motivation for change.
It helped that MI emerged contemporaneously to the transtheoretical model of change (Prochaska & Di Clemente, 1982), although MI is distinct. The transtheoretical framework emphasizes motivation for change as a continuum and the importance of meeting clients at their own motivational level across the stages of precontemplation, contemplation, preparation, action, and maintenance (and potentially relapse, returning a person to an earlier stage). MI is highly compatible with this perspective, to the extent that it is suited for working with clients who are less motivated and can be understood as a strategy for moving them forward in terms of stages of change (Miller & Rollnick, 2013).
MI is less a therapeutic technique than a method of interacting with clients. To capture the “MI spirit” (Miller & Rollnick, 2013), there are four core principles. The client-clinician relationship is seen as a partnership, an active collaboration between experts: the clinician, who possesses professional expertise, and the client, who is an expert on himself. The MI spirit emphasizes acceptance, defined as actively trying to respect the client’s autonomy, understand the client’s perspective, and recognize the client’s strengths and efforts (see chapter 24). Importantly, acceptance does not imply that the clinician must agree with or endorse the client’s beliefs and actions. Another principle is compassion, which involves a genuine effort to prioritize the client’s needs, goals, and values, albeit with an orientation toward behavior change and healthy outcomes. Finally, the principle of evocation refers to the assumption that the client already possesses all of the qualities and wisdom needed to change, and that the clinician serves as a guide who can help the client call forth her own motivation and strengths in order to achieve goals.
Several interactional elements are critical in client-clinician communication, denoted by the acronym OARS (Miller & Rollnick, 2013), which refers to asking “open” questions, “affirming,” using “reflective” listening, and “summarizing.” An interactional style characterized by the four elements of OARS is the foundation upon which the clinician develops discrepancies between the client’s current situation and his or her priorities and values. Understanding what people value and how their current behaviors are in conflict with those values is key to resolving the conflict and moving the client in the direction of change (see chapter 25). This can take place via open-ended questions (e.g., “What do you hope your life will look like in one year? What about in ten years?”), or via specific techniques discussed below.
In addition to considering what one says as a clinician, it is also critical to be aware of what one hears from a client. MI is somewhat unique because the client’s speech provides immediate feedback that can inform the clinician’s approach to an issue. Change talk is any client language that suggests the client is considering the possibility of positively changing a particular behavior. In contrast, sustain talk is any language that favors the status quo.
Increasing change talk is a key process that fosters MI effects (Amrhein, Miller, Yahne, Palmer, & Fulcher, 2003; Moyers et al., 2007). Apodaca and Longabaugh (2009) investigated MI change mechanisms for substance-use treatment and found that both in-session client utterances in favor of change and experiences of a behavior-value discrepancy were related to better outcomes, whereas MI-inconsistent behaviors (e.g., confronting, directing, warning) on the part of the clinician were associated with poorer outcomes.
It appears that change talk requires a certain level of cognitive facility in order to be effective. A recent study of MI for cocaine use (Carpenter et al., 2016) found a relationship between in-session client change talk and positive clinical outcomes, but only among participants who—in an experimental “relational frame” task (see chapter 7)—could learn to derive symbolic relations between cocaine-related stimuli, nonsense words, and the consequences of cocaine use.
Some clients believe that change is important but lack confidence in their ability to change. Additionally, a client’s confidence may decrease following apparent setbacks and roadblocks along the way. Therefore, a secondary goal of MI is to support client self-efficacy throughout the change process. The process for evoking client confidence talk, or ability language, is similar to evoking change talk more broadly. The clinician listens for and reflects statements that include words like “can,” “possible,” and “able.” The clinician also asks open questions to elicit information about a past instance when the client successfully made positive life changes, ideas the client has for how to go about making changes, and obstacles the client might encounter and how they could be dealt with.
Learning to recognize these different forms of talk in session is aptly described as “detecting a signal within noise. It is not necessary to eliminate…the noise, just follow the signal” (Miller & Rollnick, 2013, p. 178). Clinicians need to notice language that expresses a desire or intention to change, optimism about the client’s ability to change, reasons for or benefits of change, and the need to change or problems with continuing the way things are (Rosengren, 2009). Sustain talk may appear in the form of defending a position or behavior, interrupting the clinician, or disengaging from the conversation (e.g., ignoring the clinician or appearing distracted). An increase in sustain talk should signal to the clinician the need to “roll with resistance” by slowing down, reevaluating the conversation, or including the client in the problem-solving process (Miller & Rollnick, 2013). It may be appropriate for the clinician to apologize for misunderstanding the client, to affirm the client’s point of view in order to diminish defensiveness, or to shift the conversation away from the touchy topic rather than intensifying it. Being aware of these verbal patterns is important because clinician style affects the ratio of change talk to sustain talk (e.g., Glynn & Moyers, 2010), especially in substance-use populations. (e.g., Apodaca, Magill, Longabaugh, Jackson, & Monti, 2013; Vader, Walters, Prabhu, Houck, & Field, 2010). Beyond client treatment engagement, as measured by attendance and treatment completion, it is still unclear which specific processes contribute to positive MI outcomes in other areas of clinical work, such as mood and anxiety disorders, psychosis, and comorbid conditions (Romano & Peters, 2015).
If MI is working as anticipated, the conversation will shift from whether the client wants to change to how change can be accomplished, sometimes referred to as the choice point or decision point. To know if the time is right, the clinician should look for increased change talk (and decreased sustain talk), stronger commitment language, greater apparent personal resolve, questions about change, or signs that the client has taken concrete steps to experiment with change. When the client appears sufficiently ready, the clinician should test the water by directly asking him if he’s ready to start planning for change, either by summarizing his motivations for change or by posing a key question (e.g., “So, what do you think you’ll do?” or “Where do you want to go from here?”).
With regard to efficacy, early studies sought to determine the factors that influence client motivation for initiating formal, extended alcohol treatment (Miller, Benefield, & Tonigan, 1993; Miller, Sovereign, & Krege, 1988). These studies involved a single-session intervention that combined MI with feedback from a personal assessment of the individual’s drinking relative to norms and recommendations (i.e., “Drinker’s Check-up”; Miller et al., 1988). While the results did not show that the MI intervention provoked high rates of engagement in subsequent formal treatment, participants exhibited a significant, self-directed reduction in drinking at follow-up in general. A review of similar studies found that the effectiveness of brief MI interventions was comparable with more intensive treatments for reducing problematic drinking (Bien, Miller, & Tonigan, 1993). Given these promising findings, research on MI was expanded to evaluate its independent usefulness in different capacities and with various populations and conditions.
Since these initial findings, literally hundreds of studies have evaluated the efficacy of MI. The evidence is strongest for substance-use disorders, including the use of alcohol, marijuana, tobacco, and other drugs (Heckman, Egleston, & Hofmann, 2010; Hettema, Steele, & Miller, 2005). In a large multisite clinical trial, a four-session MI intervention generated equivalent outcomes to eight sessions of either cognitive behavioral treatment or twelve-step facilitation (Project MATCH Research Group, 1997, 1998). In addition, across an ever-expanding range of problem behaviors, MI has demonstrated significant positive effects on behavioral outcomes, including reducing risky behaviors (e.g., unprotected sex, sharing needles), promoting healthy behaviors (e.g., exercise, better eating habits), and increasing treatment engagement (for a review of four meta-analyses, see Lundahl & Burke, 2009). Across all problem behaviors studied, MI is significantly more effective than standard controls, and it is equally effective as other active treatments, though MI takes less time to implement (Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010).
Regarding treatment format, MI can be implemented as a brief, stand-alone intervention, but the effect of MI is greatest when combined with another active treatment, such as cognitive behavioral therapy (Burke, Arkowitz, & Menchola, 2003). When used in conjunction with another intervention, MI is helpful as a precursor for increasing initial client engagement and as a strategy for maintaining motivation throughout treatment (Arkowitz, Miller, & Rollnick, 2015). MI has demonstrated positive results for clients regardless of their problem’s severity, gender, age, and ethnicity, although its supportive, nonconfrontational tone may be selectively more effective for some ethnic groups, such as Native Americans who rely on similar communication patterns (Hettema et al., 2005). MI may also be more effective than cognitive behavioral therapy for clients with alcohol-use disorder who report higher levels of trait-level anger and dependence (Project MATCH Research Group, 1997).
With regard to in-session tools, perhaps the most versatile and efficient measures are motivational “rulers” or “ladders” (Boudreaux et al., 2012; Miller & Rollnick, 2013). These are single-item questions that assess readiness to change, importance of change, and/or confidence in the ability to change (on a scale from 0 to 10). They can be administered verbally, on paper, or via computer and serve two main functions. First, these measures quantify the client’s motivation in a short and face-valid way. Second, these measures allow the discussion to ramify around the reported number. For example, self-efficacy can be explored by asking what makes the client’s rating of confidence 8 out of 10 or why the client’s rating of importance is 9 out of 10. Importantly, asking what makes these values as high as they are elicits pro-change statements (e.g., what makes them feel ready or gives them confidence). However, the opposite is also true: asking clients why their ratings are not higher will elicit reasons to not change and thus should be avoided.
Another strategy for implementing MI is to collaboratively complete a decisional balance exercise or change plan. These are relatively short procedures that formalize either the costs and benefits of the problematic behavior or the steps that will be taken following the session. The decisional balance exercise involves collaboratively completing a two-by-two matrix that crosses costs and benefits with the status quo versus making a change. It is a simple and straightforward way for the client and clinician to articulate and formalize the impelling and countervailing motivational forces at hand. However, an embedded risk within this tool is that the fully crossed matrix includes a focus on reasons not to change and costs of changing. Thus, it can have the unintended consequence of evoking sustain talk if used unskillfully.
A change plan is a worksheet the client completes while in discussion with the clinician. Common sections include the changes the individual wants to make, the most important reasons for doing so, the steps that are already being taken, potential impediments, people who can help, and benchmarks for success. A benefit of the change plan is that it provides the clinician with an oblique angle from which to encourage the client to describe objective goals. If the desired change is too nebulous, the goal is undermined because it is unclear whether a person is succeeding or failing, except in gross terms. For example, “It’s time to get my drinking under control” is an excellent example of change talk, but it is largely undefined. Conversely, “I really need to not drink at all during the week and no more than four drinks on Friday and Saturday night” reflects both change talk and clear objective goals that can be targeted and achieved.
These two tools can be thought of as bookends to the choice points that naturally emerge in treatment; the decisional balance exercise reflects the critical process of cultivating maximum motivation to change, and the change plan provides a format for identifying objective goals and plans, after the client and clinician have agreed that change is a priority. The clinician often gives these worksheets to the client, and they can serve as powerful reminder stimuli between sessions.
A lengthier strategy is a structured card-sorting exercise regarding values (see chapter 25). For this activity, the client categorizes up to one hundred pregenerated and client-generated values in piles based on how important the listed values are to him. The clinician follows up the activity by asking open-ended questions that lead the client to explore why the selected values are important and how they are expressed (or not expressed) in the client’s life. This can then be followed up with questions about how the presenting problem is incongruent with the client’s personal values. The activity can take a full session, and it provides a powerful way for a person to operationalize personal values and consider the effects of the presenting problem in direct juxtaposition to those values.
Two additional implementation recommendations may also be useful. First, a microtechnique that can be very powerful is integrating direct invitations to clients over the course of the therapeutic dialogue. For example, this might happen when a clinician transitions from unstructured dialogue to a more structured aspect of the session, such as offering objective feedback about performance on specific assessments (e.g., drinking levels, symptom severity): “Next, I’d like to give you some objective feedback about how your drinking compares with other students here. Would you like to see that?” (or “Are you interested?” or “How does that sound?”) These invitations typically elicit an affirmative response (and are highly informative when they do not) and implicitly emphasize client autonomy and agency, communicating to clients that proceeding is their choice. Including direct invitations intermittently is a small way of communicating respect for the client and fostering a collaborative partnership.
Second, an implementation strategy that helps orient the clinician is to consider the function of therapeutic in-session behavior in terms of the MI components: expressing empathy, developing discrepancy, rolling with resistance, and supporting self-efficacy (Miller & Rollnick, 2002). For example, developing a change plan and problem solving specific behavior-change strategies clearly support self-efficacy. Explicitly considering how an activity or dialogue fits into a domain of MI can be especially useful for novice clinicians.
A variety of additional tools and measures are available to support MI work (see http://www.motivationalinterviewing.org), but a comprehensive review is beyond the scope of this chapter. Nonetheless, given the large and rich array of resources, it is recommended that clinicians leverage them as much as possible.
Motivation to change is a key issue in all forms of clinical intervention. MI is a framework for thinking about how clinicians can help clients help themselves; it is a mind-set that recognizes the fluctuating nature of motivation and its essential importance in behavior change.
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