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Motivational Interviewing: A Guide to the Art & Skill
When I was going through residency training several years ago, I was introduced to somethingthing that produced a truly radical shift in me and my practice.
During residency, much of our didactic content was taught by Joe Godges. If you don’t know Joe or haven’t heard of him, he is an expert clinician in the truest sense of the word. Which, to me, means someone with a true beginner’s mind, which Joe certainly has.
Part of what he taught us in these courses was the communication style known as Motivational Interviewing.
Prior to being exposed to MI, I hadn’t realized that there are ways of talking with people that can help them get unstuck. This was a huge realization for me.
After this course, I fully nerded-out on MI for many years.
It started with buying the textbook [1] written by the creators of MI, Miller & Rollnick, and reading about two-thirds of it while I was forced to take time off from residency while recovering from eye surgery (kind of eye-ronic that I read a book while recovering from eye surgery. I considered it rehab, or something like that).
I then was able to take several courses and workshops that were offered through my hospital system, as well as shadow some rehab psychologists to see it in action.
Before I left Baltimore, I had the privilege of teaching the MI content to the residents during their didactic modules in a nice full-circle manner.
I want to share with you the gift of MI, while also helping you to avoid some of the ways that I’ve misunderstood, misinterpreted, and all-out fucked up when trying to implement MI in the clinic.
My hope is that you can leapfrog my mistakes and walk as smooth of a path as possible toward implementing MI in the clinic.
In this guide, we’ll talk through:
(Click the blue links to jump to that section of the guide)
Along the way, I’ll give you some exercises and ways of practicing and implementing the material.
My advice:
There’s A LOT of information in here. Choose one, maybe two exercises to focus on for several days or weeks, then layer on another when you have the first one down. Trying too much, too fast was unquestionably one of my first mistakes.
Another great way to practice is to try out these techniques in your daily life (shout out to my wife who endured my practicing MI on her for a good while before she started kindly telling me to fuck off— this just goes to show that I was focusing on the skills more than the mindset behind the skills, as we’ll discuss).
If you want some habit hacks to make the skills more likely to happen, you can use the infographic with 4 intention-setting practices in the Clinical Reasoning blog post.
That’s enough of a preface, don’t you think?
What is MI?
Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change.
It’s designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.
This second bit really speaks to the mindset or spirit of MI. The strategic aspects of MI are intended to help the person resolve dissonance and move toward their own goals. But a MASSIVE part of our ability to help them do this lies in our ability to create an atmosphere of acceptance and compassion.
When is MI helpful?
Motivational interviewing can be helpful any time we’re working with someone on changing their behavior.
How much of our job involves behavior change? Pretty much all of it.
Much of what we do involves behavior change in one way or another:
Activity modification
HEP performance, consistency
Lifestyle change
Adherence to precautions
Showing up on time
Response to pain
Problem-solving behaviors
All these things require the person to change their behavior in some way.
The problem with behavior change
The problem that we and our patients often run into is that behavior change is hard. It takes focus on a particular goal, commitment, and action toward that goal.
When people feel stuck on this path, one of the main culprits is often something called ambivalence. Ambivalence is simultaneously wanting and not wanting something, or wanting both of two incompatible things.
For example,
I could want to exercise and not feel like it at the same time
I could want to exercise and also want to binge-watch the office
I could want to be healthy and also want to eat pizza tonight
It’s quite common that we find ourselves feeling two ways about aspects of our lives, especially aspects that we regard as problematic. Resolving this ambivalence and helping people move toward aligned action is at the root of what MI is all about.
What does ambivalence look like?
When someone is ambivalent, it’s normal to hear two kinds of talk mixed together.
The first kind of talk is called Change Talk— the person’s own statements that favor change
The second kind of talk is called Sustain Talk— the person’s own arguments against change, or for the status quo
I like to think of little committee members having a meeting inside our heads. Sometimes the pro-change members speak, other times the anti-change members speak.
This mixture of language might sound like…
“I know I need to exercise to be healthy [change talk] but I’m exhausted after work [sustain talk].”
“I know I should do my exercises [change talk] but I just don’t have time [sustain talk].”
The BUT is a key indicator of ambivalence.
A thought experiment...
Think about something that you’re ambivalent about. Something that you feel two ways about. Try and hold that in your head as we talk through this thought experiment.
I’m going to use drinking as an example:
You know that you want to drink less, but you enjoy a beer or two after a long day as a way to unwind and relax.
Now, suppose you tell me this and in response, I say, “You know, alcohol is known to cause heart problems, digestive problems, cancer, weakening of the immune system, and can increase the likelihood of dementia… “
You’d probably tell me that you know most of that to be true… BUT [insert reason you still drink].
And I say, “Doesn’t that scare you? Isn’t your health important to you??”
You’d probably say, “Yes it does, and yes it is… BUT [insert competing desire].
Why would you respond in this way? Because you’re ambivalent! You have reasons to drink AND reasons not to drink.
And the more I try to voice the arguments against alcohol use, the more I elicit your reasons and arguments for alcohol use. This is a Fundamental Principle of MI: argue for one side and the ambivalent person is likely to take up and defend the opposite.
In this scenario, if my goal is to help you move toward what you said you want—drinking less—I have it exactly backward.
You’re much more likely to change your behavior if you’re the one voicing the reasons for change, not me. This is because of another Fundamental Principle of MI: most people tend to believe themselves and trust their own opinions more than those of others.
So, what if instead of telling you what you should do and why you should do it, I ask you some questions, like…
“What makes you want to drink less?”
“What is it about drinking that you don’t like?”
“What would help you to drink less if you decided to?”
These questions would likely elicit an entirely different response from you.
Let's explore why.
The Righting Reflex
The directing style that I presented first is an expression of what’s known as the righting reflex: the desire to fix what seems wrong with people and to set them promptly on a better course.
This reflex lives within most of us, especially those of us in helping professions. Helpers wanna help. We want to set things right, to get people on the road to health, wellness, and success.
The problem is that telling people what to do or giving people reasons that they should do something is likely to trigger a reaction in them, especially when they’re ambivalent.
MI shows us how to skillfully work with people to help them explore both sides of ambivalence in order to make the right decision for them.
And it all starts with our attitude.
The Spirit of MI
The mindset behind MI or the Spirit of MI, as the creators dubbed it, is the underlying perspective, attitude, or mindset, with which one practices MI.
If I’ve learned one thing about MI it’s that this is by far the most important aspect of MI. One of the biggest ways that I’ve misused MI in the past was by over-focusing on the skills and under-focusing on the attitude.
Miller & Rollnick put it this way:
"Without this underlying spirit, MI becomes a cynical trick, a way of trying to manipulate people into doing what they don’t want to do, a battle of wits in which the goal is to outsmart your adversary [1].”
This is NOT what it’s about.
If you truly want to help people, which I’m certain that you do, it’s about helping people move toward their own self-identified goals within their own value system.
If you truly embody the spirit of MI, the skills will come naturally. And It doesn’t work the other way around.
The 4 Components of the Spirit of MI
1. Partnership
Motivational interviewing is based on active collaboration between partners, not an expert and a passive recipient.
A common metaphor here is that it should feel like dancing, not wrestling. Someone can lead the dance, and skillful guiding is certainly part of the art of MI, but the two must move and work together in order to avoid tripping and stepping on toes.
A common pitfall is what’s known as the expert trap: communicating—explicitly or implicitly—that you are the expert and you have the answers to the person’s dilemma.
Of course, we do have expertise and much to offer our patients, but our advice and expertise must fit within the context of their own life and values for it to be useful to them. This is where we need them to be an active participant, a partner.
Avoiding this trap includes letting go of the assumption that you are supposed to have and provide all the right answers. I don’t know about you, but I find this tremendously freeing.
2. Acceptance
Acceptance means:
Respecting the other as having worth in their own right
An ability to understand the other person’s frame of reference, and the conviction that it’s worthwhile to do so
Honoring and respecting the person’s autonomy
The beautiful thing about acceptance is that when we directly acknowledging a person’s freedom of choice, it typically diminishes defensiveness and can facilitate change.
Acceptance allows people to feel safe to change, without judgment. This requires our letting go of the idea and burden that we have to (or can) make people change. A relinquishing of a power that we never had in the first place.
What acceptance is not:
To accept a person in this sense does not mean that I necessarily agree or approve of the person’s actions.
My personal approval (or disapproval) is irrelevant. It’s not my life. I’m just here to help them in the way in which they want to be helped.
3. Compassion
Compassion is a sense of concern that arises when we are confronted with another’s suffering and feel motivated to see that suffering relieved [2].
To be compassionate is to actively promote the other’s welfare, to give priority to the other’s needs. Our services are, after all, for our patients’ benefit and not primarily for our own.
It’s always important to realize that we need not literally ‘suffer with’ in order to act with compassion. If someone chooses not to change, this is not our burden to bear, and it’s OK for people not to change if they’re not ready to change. This requires honest conversations, a part of good care.
4. Evocation
So much of what happens in professional consultations about change is based on a deficit model. A deficit model says, “This person is lacking something that needs to be installed.”