10 Addictions psychiatry10.7 Recovery-oriented interventions
10.7 Motivational interviewing
4 min read
Written by Resident Doctor Committee · Published
Origins and spirit
Motivational interviewing is a collaborative way of strengthening a person's own motivation and commitment to change.
William R. Miller introduced it in 1983 from work with problem drinkers, and later developed it with Stephen Rollnick.
Its spirit rests on partnership, acceptance and compassion, with evocation: motivation and reasons for change lie within the person and are called forth rather than supplied by the clinician.
The fourth edition widens evocation to recognising the person's strengths and resources, and its spirit also includes empowerment.
The fixing reflex (formerly the righting reflex) is the clinician's urge to solve the problem; arguing for change makes an ambivalent person argue back for staying as they are.
The principles
Miller and Rollnick's principles are expressing empathy, developing discrepancy, rolling with resistance and supporting self-efficacy.
The first edition added a fifth, avoiding argumentation.
Developing discrepancy makes the gap between current behaviour and the person's own goals or values visible to them, without confrontation, induced self-criticism or reliance on external incentives.
Motivational interviewing works by raising the person's own cognitive dissonance between behaviour and goals, whereas conditioning-based interventions and relapse prevention use dissonance only to defuse it.
Rolling with resistance means accepting and reflecting the person's reluctance rather than confronting or arguing against it.
Ambivalence, change talk and discord
Ambivalence is holding reasons for and against change at the same time, and it is distinct from resistance.
Change talk is the person's speech in favour of change, and sustain talk is speech favouring the status quo. Both are normal expressions of ambivalence.
Eliciting change talk, drawing the case for change out of the person, is a core strategic technique.
Type | Element (DARN CAT) | Sounds like |
|---|---|---|
Preparatory | Desire | "I want to be around for my kids" |
Preparatory | Ability | "I stopped for six months before" |
Preparatory | Reasons | "The scan frightened me" |
Preparatory | Need | "I need to do something" |
Mobilising | Commitment | "I will stop on Monday" |
Mobilising | Activation | "I am ready to book an appointment" |
Mobilising | Taking steps | "I poured the rest away" |
Resistance is now split into sustain talk and discord.
Feature | Sustain talk | Discord |
|---|---|---|
What it is | Reasons to continue the behaviour | Friction with the clinician |
Sounds like | "Drinking helps me sleep" | Arguing, interrupting, withdrawing |
Response | Reflect and explore concerns | Re-establish collaboration and autonomy |
Importance and confidence are separate: a 0 to 10 ruler explores each, and asking "Why four rather than one?" invites reasons for change.
Ask-offer-ask gives information: find out what the person knows, offer what is relevant, then ask what they make of it.
OARS micro-skills
Skill | Point to remember |
|---|---|
Open questions | Invite exploration ("What concerns you about your drinking?") |
Affirmations | Affirm specific effort or strengths |
Reflective listening | A tentative statement, not a question |
Summaries | Gather themes and represent the ambivalence fairly |
A simple reflection restates content, and a complex reflection adds meaning or feeling.
A double-sided reflection acknowledges both sides and usually ends on the person's reasons for change.
The four tasks
The fourth edition's overlapping tasks (formerly processes) are engaging, focusing, evoking and planning, and any of them can be revisited.
Stages of change
Prochaska and DiClemente's transtheoretical model grew up separately from motivational interviewing, and clinicians need not assign a stage.
Stage | What defines it | Time frame |
|---|---|---|
Precontemplation | Does not see a problem; minimises or denies risks, even when others are concerned | No intention to change |
Contemplation | Sees a problem and weighs costs and benefits while ambivalent; no decision, date or plan | Considering change within about six months |
Preparation | Has decided, has a concrete plan and takes small first steps; behaviour not yet changed | Intends to act within about a month |
Action | The target behaviour itself has changed; relapse risk is highest | First six months of change |
Maintenance | Works at preventing relapse | Change sustained beyond six months |
Termination | No temptation in high-risk situations, complete self-efficacy, no effort to stay abstinent | Theoretical stage after maintenance |
A resigned precontemplator accepts the harm but has no intention of changing and no hope after repeated failure, so insight is present without intention.
Cutting down does not count as action for smoking, because action needs the target behaviour itself to have changed.
Contemplation is told from preparation by the decision: the contemplator is still weighing, while the person in preparation has decided and planned.
Six months separates action from maintenance.
Evidence and related approaches
Motivational enhancement therapy is a manualised version that adds personalised feedback.
In Project MATCH (1,726 people), it matched cognitive behavioural therapy and twelve-step facilitation, and in UKATT (742 people) it matched social network therapy at 12 months.
The 2023 Cochrane review (93 trials) found a small benefit over assessment and feedback (standardised mean difference around 0.24) and little or no difference from other active interventions.
FRAMES summarises brief intervention principles: feedback, responsibility, advice, menu, empathy and self-efficacy.