Motivational Interviewing

Description of the Strategy

Most forms of cognitive behavior therapy presuppose an adequate level of client motivation for change. They are characteristically directive and prescriptive, recommending particular changes in client behavior and cognition, and often involving homework assignments for the client to carry out between sessions. As with many other therapies, adherence to treatment prescriptions is a significant problem in cognitive behavior therapy, particularly with certain populations and target problems.

Motivational interviewing (MI) was predicated on the assumption that many people with current behavior problems are at best ambivalent about changing them, even when entering treatment. If this is so, then it would not be surprising that directive prescriptions for behavior change are met with fluctuating compliance. MI was designed to address ambivalence directly, enhancing clients' intrinsic motivation for and commitment to change. It was originally intended as a prelude to therapy, enhancing treatment adherence [Page 384]and thereby improving outcomes. There is evidence (discussed below) that MI does, in fact, enhance adherence and outcomes when added to other treatment. It became apparent quite early, however, that MI alone can also trigger behavior change and that in some circumstances, MI is itself a psychotherapeutic intervention.

MI is heavily rooted in the humanistic clientcentered counseling methods developed and tested by Carl Rogers and his students and might be regarded as an evolution of clientcentered therapy. Many of the specific methods used within MI are drawn directly from the work of Rogers, and in a real sense, one cannot competently deliver MI without first developing proficiency in client-centered counseling.

Where, then, does MI depart from a client-centered approach? The principal point of departure is that MI is consciously directive, whereas client-centered counseling has usually been described as nondirective. Within MI, the therapist seeks to elicit and differentially reinforce particular types of client speech, tipping the balance of ambivalence toward intrinsic motivation for and commitment to change. Rogers maintained that his own responding to clients was noncontingent and unconditional, although his student Charles Truax published data suggesting that, in fact, Rogers selectively reinforced certain kinds of client statements. MI assumes that therapists necessarily select the client statements to which they will respond, as well as their own responses to those statements, in a nonrandom manner. Such selective reinforcement is a conscious process in MI, directed toward specific change goals. This means that MI is useful when there is a particular behavior change goal, especially when the client is ambivalent about achieving the goal.

MI was originally described in 1983 as a method for working with problem drinkers. To say that a client is ambivalent is to assume that he or she simultaneously wants to change and wants to stay the same. Both forms of motivation are present within the ambivalent client. If the therapist takes up the prochange side of the argument (e.g., “You have a drinking problem, and you need to quit”), the ambivalent client predictably responds with counterchange arguments (e.g., “No I'm not, and I don't want to”). Such acting out of the client's ambivalence might be thera peutic were it not for the fact that people tend to be persuaded by what they themselves say. If counseling is done in a way that elicits counterchange arguments from clients, they are in essence talking themselves out of changing. MI intentionally seeks to elicit from clients their own intrinsic motivations for and commitment to change. When MI is done well, clients literally talk themselves into change.

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