Motivational Interviewing Jassin M. Jouria, MD MI INTRODUCTION Motivational interviewing (MI) is a method that promotes behavior change, and can be used in a multitude of environments and situations to foster growth and to help people to take on challenging situations. Motivational interviewing is a collaborative process that edifies the client and makes him or her responsible for personal choices. It is not necessarily a stand-alone type of therapy, but instead can be incorporated into treatments and routine care for clients with various health issues, including those with physical health problems, mental health issues, or substance abuse and addiction. MI has also successfully been used along with other forms of therapy to improve connection between the client and the provider and to alter the process at which the client makes changes in his or her life. Therapists can use motivational interviewing in a number of situations, yet it should always be recognized that no one could be forced to change. Although the goal of MI is not to directly change a person’s behavior, it does guide the client toward making different choices that can foster change in his or her life. The concept of motivational interviewing began in the early 1980s with the publication of a book by William R. Miller, PhD, who focused his model of MI on working with people suffering from substance abuse and addiction. The book was titled Motivational Interviewing with Problem Drinkers and it was initially used among psychiatrists and other professionals who provided counseling services for people going through treatment for addiction [5]. ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 1 Almost twenty years later, Miller and a colleague, Stephen Rollnick, published a second edition of the book. The second edition was geared, not only toward addiction professionals working in the field of psychotherapy, to any professional in the healthcare field who could utilize the principles and put the techniques of MI into practice with their clients [5]. Miller and Rollnick described motivational interviewing as a “directive, client- centered counseling style for eliciting behavior change by helping clients to restore and resolve ambivalence” [5]. Ambivalence is a state in which a person is uncertain about which direction to take, if any. A person who feels ambivalent about his or her need for change or required treatments may approach the situation with a lack of motivation. The person may have such mixed feelings about the situation that making a decision can be paralyzing. When a therapeutic relationship starts, the client may be in various stages of ambivalence depending on the current situation. If he or she was recently diagnosed with an illness or disease, ambivalence may be paired with frustration or anger over the situation. Alternatively, the client may have known for quite some time that change is necessary but has been unwilling or unable to take steps to move forward. Motivational interviewing is more than just a set of techniques that can be implemented into conversations between healthcare providers and their clients. It recognizes several theories as a basis for its approach, including cognitive dissonance theory, which acknowledges that a person who acts against his or her beliefs will be motivated to either change behaviors or otherwise justify them; and self-perception theory, which is the idea that people conclude certain traits or ideas about themselves based on observing their own behaviors [33]. ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 2 A basic premise exists in motivational interviewing that talk can be helpful for some situations, but without the motivation to change, talk, or simply telling a person to do something, will not get very far. The provider who is working with a client through motivational interviewing must recognize the level of motivation the client holds and must be willing to work through possible resistance to change in order to foster goal setting and to move forward [33]. Motivational interviewing can be used in many different types of specialties for helping clients to change. Although it may be considered a therapeutic approach that would traditionally be used in counseling or in sessions with a psychologist, motivational interviewing can actually be a part of some routine meetings or examinations for brief sessions. Motivational interviewing has been used successfully in implementing change in numerous situations, such as with drug or alcohol addiction, smoking cessation, vocational rehabilitation, criminal justice, pregnancy, and as a component of treatment for many different medical conditions [29]. Similarly, motivational interviewing is not simply designated for counselors or psychologists. It can be successfully implemented into appointments or interactions with various healthcare providers, including nursing staff, primary care physicians, nurse practitioners, or allied health professionals. There is some formal training available in developing the techniques associated with motivational interviewing, although learning the techniques and the process of MI is typically either integrated into formal education programs, or through stand-alone training opportunities, such as through workshops, conferences, or online educational programs. The Motivational Interviewing Network of Trainers (MINT) is a non-profit organization that was started by a group of MI practitioners who were originally trained by Miller and Rollnick in MI techniques. MINT promotes the ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 3 use of motivational interviewing, as well as continuing research and appropriate training of practitioners. The organization is composed of independent trainers and practitioners and can give details about specific educational opportunities for those who want to learn more about motivational interviewing and to put its methods into practice [30]. STAGES OF READINESS FOR CHANGE The ultimate goal of working through motivational interviewing is to move the client through the various stages of change, from being ambivalent or unmotivated to dealing with unhealthy behavior and making more positive choices [21]. The stages of readiness for change is actually a cycle of steps identified by James Prochaska, and each step requires various interventions to move the client on to the next step. The stages of change include: precontemplation, contemplation, preparation, action, maintenance, and termination [21, 22]. The precontemplation stage occurs before the client is even aware that a change needs to happen. Family members, friends, and significant others may easily recognize that the client has a problem or that change needs to happen but the client is often unaware. During this phase, the client is resistant to change because he or she does not understand its necessity. The client may even be aware that life is difficult or there are several aspects of life that demand attention that he or she cannot handle, but the concept of change is still foreign. The contemplation stage is when the client recognizes that a change needs to happen. It is often at this stage where motivational interviewing begins. Although the client may recognize the need for change, he or she may be so ambivalent about making the change or what steps to take that no change ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 4 occurs at all. Many people remain in the contemplation stage for years, always feeling that something needs to be done, but never taking steps to do anything. The preparation stage involves planning to make a change soon. People in this stage may still be ambivalent about what to do, but they are planning to try for a change. They may be uncertain that their plans are the best for solving their situation and so may still be somewhat ambivalent about making choices toward change. They often need to convince themselves that change is necessary and that their plans are the best method of working through the problem. The action stage involves taking the steps to overcome the problem. It is during this stage that the client does a lot of activity that demonstrates working toward the change, such as quitting smoking or exercising more. Others can see the client’s work toward the change as well, which can be encouraging. This stage also requires the most energy to continue with changes, even if they are uncomfortable. The maintenance stage is the ongoing phase that may be life long for some people. This stage occurs after a person has done the work of making changes but then needs to continue to make efforts to maintain the results. For example, a person who has lost 50 pounds needs to maintain the weight loss by continuing with efforts that he or she implemented to lose the weight in the first place. If the person does not maintain the work, he/she may gain the weight back. The termination phase is one in which the initial issue is no longer a problem. Some people never reach this phase while working for change, as ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 5 the principles they developed and the work they completed must continue to be maintained and reinforced for the rest of their lives. For others, the termination phase results when the initial change or struggle is no longer a problem and they can move forward into other activities without continuously maintaining their previous efforts [22]. Key principles Motivational interviewing can be broken down into key principles, followed by significant processes that are used. Each process or principle is then supported by various therapeutic techniques. Each technique may serve to uphold or meet the goals of one or more principle or process throughout the interview. To start, motivational interviewing consists of four key principles that guide practice, which are empathy, discrepancy, rolling with resistance, and supporting self-efficacy [5].