Motivational Interviewing

I. Learning Objectives

• A. Participants will increase their knowledge of motivational interviewing.
• B. Participants will increase their skills in conducting motivational interviewing.

II. Chronology

• A. 20 - 40 minute large group lecture using a sub-sample of about 30 slides.
• B. 10 - 20 minute demonstration role-play.
• C. 10 - 20 minutes participants practice role-play.

III. Training Materials

• A. How Does Behavior Change? [HTML] 27 slides.
• B. Summary of clinical protocols.
• C. Role-play scenarios; see Appendix B.

Introduction

Motivational interviewing (MI) is a technique designed to help students and others change a specific health behavior such as alcohol use. William Miller (1983) is given credit as the first person to describe MI as a counseling technique. MI is client-centered as opposed to clinician-centered. The focus is on helping students arrive at the conclusion that they need to change a behavior. These behaviors may be reducing their alcohol use, stopping smoking, increasing exercise, changing dietary habits, decreasing risk for STDs, etc.

MI is similar to many of the basic skills taught in doctor/nurse/social work training on basic patient communication. Many elements of MI are identical to what physicians, nurses, social workers, and other health care professionals have used for centuries to convince patients to take their medications, change a health behavior, or follow through on completing a test or procedure.

MI is based on a number of assumptions. These assumptions include: a) the theory that most people move through a series of steps prior to changing their behavior; b) change comes from within rather than from without; c) confrontation and negative messages are ineffective; d) knowledge alone is not helpful; and e) reducing ambivalence is the key to change. This is an active area of research in which all of these assumptions are being studied and tested. While there is much to learn about its effectiveness with college students, many clinicians have found that skill in MI techniques enhances the delivery of brief intervention.

What is Motivational Interviewing?

MI is a way to help students recognize they have a problem and need to make a change. Many students seeking care in a student health center are already concerned about their drinking, tobacco use, or some other behavior. They just don't know where to start. MI attempts to "unstick" students, so they can begin to change. MI techniques create an openness and readiness to change. Some students will change after one or two MI encounters, while others may require more intensive counseling.

Key Elements of MI

1. Express Empathy

Empathy is based on respect, an acknowledgement of the student's perspective, and acceptance of the student's point of view. The clinician tries to understand without criticizing, judging, or blaming. Reluctance to give up a behavior such as high-risk drinking is a normal psychological process. It is not pathological. However MI does not give the student permission to continue his/her high-risk behavior. Acceptance of a student's position is not the same thing as agreeing with the student's position or condoning high-risk alcohol use. The next principle is designed to change the student's position by developing discrepancy.

2. Develop Discrepancy

Many students understand their alcohol use is having an adverse effect on many aspects of their lives. They understand they are at risk for alcohol-related accidents, injuries, and academic problems, especially if they are under 21 years of age. While they like to drink and party, they also recognize many of the negative things associated with high-risk drinking. Discrepancy seeks to amplify, intensify, and accentuate these negative thoughts and ambiguous feelings about their alcohol use. Discrepancy tries to help students set personal goals such as academic success, health, and strong personal relationships above their desire to use alcohol. MI tries to identify specific examples of how the drinking resulted in an experience that conflicted with the students' personal goals, values, and internal beliefs about themselves.

3. Avoid Argumentation

Direct argumentation often evokes resistance and hardening of the student's position. MI uses low-key persuasion. MI tries to start from the student's position and to work from that point. Strong statements such as - "You are in denial." or "You are alcoholic." - often lead to an increase in student resistance. From a harm-reduction paradigm, clinicians will help more students reduce their alcohol use by spending two minutes with 10 patients using MI techniques than arguing with one student for 20 minutes.

4. Roll with Resistance

Jay Haley, who is an expert on family therapy, coined the term "psychological judo". As with judo and martial arts, one can use a student's own momentum to move them into a fall or a different position. MI can move students such that they say, "How did I get here?" Reluctance to change is acknowledged by the therapist as normative, based on the students' perception of their alcohol use and its relationship to their peers and environment.

5. Support Self-Efficacy

A fifth MI principle is self-efficacy. Students need to believe they can change and successfully reduce their alcohol use. Hope and faith are important elements of change. Clinicians can use positive statements to facilitate the sense that students can alter their behavior. The other element of self-efficacy is taking personal responsibility for change.

MI Techniques

• Use open-ended rather than closed-ended questions.
• "Tell me about your drinking."
• "What concerns do you have about your drinking?"
• "How can I help you with your drinking?"
• Use reflective listening to focus on students' concerns and ambivalence toward their alcohol use.
• "I hear you."
• "I'm accepting, not judging you."
• "Please say more."
• Use affirmative statements in order to gain students' trust and confidence.
• "You are very courageous to be so revealing about this."
• "You've accomplished a lot in a short time."
• "I can understand why drinking feels good to you."
• Use summary statements.
• "What you said is important. I value what you say. Here are the salient points."
• "Did I hear you correctly?"
• "We covered that well. Lets talk about …"
• Elicit self-motivational statements - these statements fall into four categories.
• Problem recognition - "I never realized how much I am drinking." "Maybe I have been taking foolish risks."
• Expression of concern - "I am really worried about my grades and how alcohol may be affecting them."
• Intention to change - "I don't know how but I want to try."
• Theme about optimism - "I think I can do it. I am going to overcome this problem."

Additional points that may be helpful to primary care providers utilizing MI:

1. The primary goal of MI is to resolve ambivalence and resistance and move students into a commitment to change their alcohol use.

   Move student From the following position:
   "I am not interested in reducing my alcohol use. I drink less than my friends." " I see no reason to change how much I drink. It is part of the college experience. I am not having problems so why should I cut down?"
   To:
   "If I stop drinking I will feel better and maybe do better in school. However I am not sure what my friends will think. I am not sure how I can party and have fun if I don't drink so much." To: "Maybe I do drink too much. I am willing to try to cut down. How much do you think it is safe for me to drink?"

2. Motivation to change is elicited from the student from within. It is not imposed from without. MI does not involve the use of external threats.

   Provider statements not based on MI:
   "If you don't stop drinking, you will be expelled."
   "If you don't stop drinking, you will lose your job."
   "If you don't stop drinking, you will never get into graduate school."
   "If you don't stop drinking now, you will turn into an alcoholic."

3. In MI, the clinicians are not passive agents or mirrors. They direct and facilitate change with a number of methods. Clinicians utilize empathy, summarization, reflective listening, and other techniques. MI is not 100% clinician-directed or 100% client-centered but rather someplace in between. It is meant to be interactive, with both sides giving and taking. In this way, it is similar to developing a relationship based on mutual respect, trust, and acceptance.
4. MI avoids arguments, coercion, and labels. While a therapist using MI techniques may not agree with a student, he/she respects the student's perspective. A counselor can disagree. For example:

   Student: "Doc, I don't think I have a problem or need to cut down."
   Provider: "John, I have to respectfully disagree. You had a serious accident after you were drinking. You are not doing well in your classes. Your girlfriend left you. I am not sure how serious things are, but I think you should consider how alcohol is contributing to these problems."

5. MI does not use negative comments or scare tactics. MI reframes consequences and negative aspects of student drinking. Here is an example of provider statements that use MI techniques:

   "The X-ray on your arm that we took today suggests your broken arm is healing well. Based on the extent of your injuries, it sounds like you had a serious accident. Your medical record says you had a blood alcohol level of 0.16. How about telling me about the accident and the role of alcohol in that accident?"

6. MI insists that students take an active role in the decision to change their alcohol use

   Provider: "Only you can decide to reduce your alcohol use. This is your decision. I am here to treat your medical problems and to hopefully prevent you from getting into trouble with your drinking. What do you think about agreeing to cut down for a month or two and seeing how it goes?"

7. MI is not necessarily used when clinicians conduct brief talk therapy or brief intervention (BI). While the most effective way to conduct BI is to utilize MI techniques, BI can be 100% provider-directed. Provider-directed BI does, however, appear to be less effective with students. The following is an example of a100% provider-directed scenario.

   An example of brief intervention without the use of MI principles: "John, you drink too much. It is bad for you. It will affect your grades and you may have a serious accident. You may forget to use a condom and acquire an HIV infection. As your doctor, I am recommending that you to cut down to 3 or 4 drinks when you go to party with your friends."

This type of interaction is clinician-directed; it does not take into account the student's readiness to change or other factors (e.g., untreated depression, anxiety, tobacco addition, other drug use, or stress) that may make change very difficult for John.


8. MI is not the same as cognitive behavioral therapy (CBT). CBT is designed to teach skills. MI is designed to deal with ambivalence. If necessary, CBT can occur after MI has convinced students they need to change their alcohol use. CBT offers very specific strategies students can use to successfully reduce their alcohol use. However, in order to use CBT, a student must first be motivated to change.

References

Fleming, M.F., Mundt, M.P., French, M.T., Manwell, L.B., & Stauffacher, E.A. (2002); "Project TrEAT, a Trial for Early Alcohol Treatment: 4 Year Follow Up;" Alcohol, Clinical and Experimental Research, 26, 36-43.

Handmaker, N.S. & Wilbourne, P. (2001); "Motivational Interventions in Prenatal Clinics;" Alcohol & Research Health, 25, 219-21-9.

Miller, W.R. (1983); "Motivational Interview With Problem Drinkers;" Behavioral Psychotherapy 11, 147-172.

Miller, W.R. (1985); "Motivation for Treatment: A Review With Special Emphasis on Alcoholism;" Psychological Bulletin. 98, 84-107.

Miller, W.R., Benefield, R.G., & Tonigan, J.S. (1993); "Enhancing Motivation for Change in Problem Drinking: A Controlled Comparison of Two Therapist Styles;" Journal of Consulting and Clinical Psychotherapy, 61, 455-461.

Marlatt, G.A., Baer, J.S., Kivlahan, D.R., Dimeff, L.A., Larimer, M.E., Quigley, L.A., Somers, J.M, & Williams, E. (1998); "Screening and Brief Intervention for High-Risk College Student Drinkers: Results From a 2-Year Follow-Up Assessment;" Journal Consult Clinical Psychology, 66, 604 615.

Monti, P.M., Colby, S.M., Barnett, N.P., Spirito, A., Rohsenow, D.J., Myers, M., Wollard, R., & Lewander, W. (1999); "Brief Intervention for Harm Reduction With Alcohol-Positive Older Adolescents in a Hospital Emergency Department;" Journal Consult Clinical Psychologist, 67, 989-994.

Historical document
Last reviewed: 9/23/2005