Keywords

Introduction

The Motivational Interviewing initially aimed to motivate changes people with problems related to the consumption of alcohol and other drugs. In this context, it was found that these individuals had great difficulties in changing their behavior, even with their lives in ruins, being seen as resistant to change. In the 1980s, the Motivational Interviewing in the health environment emerged, acting especially in alcohol dependence, being concerned, above all, with adherence to treatment (Rollnick, Miller, & Butler, 2009).

The authors William Miller and Stephen Rollnick believed in the possibility of offering a new, more dignified approach, taking into account mainly the motivation and ambivalence within the process of change. On the other hand, at that time when treatments were mainly guided by the principle of confrontation: they believed that people with problems related to the use of alcohol or drugs had very rigid defenses, which prevented them from recognizing their situation and, consequently, treating them would only be through confrontation (Miller & Rollnick, 2013; Rollnick et al., 2009).

Historical Overview

Initially, in its first edition, the Motivational Interviewing focused on people with problems related to alcohol and other drugs. However, soon after its first publication, several studies were conducted and it is now possible to find the Motivational Interviewing in other fields of intervention, with emphasis on family and justice (Simmons et al., 2016), sexual risk behaviors (Pettifor et al., 2015), nutrition in young diabetics (Nansel et al., 2015), pregnant and obese women (Lindhardt et al., 2015), oral health prevention (Masoe, Blinkhorn, Taylor, & Blinkhorn, 2015), and even the use of Motivational Interviewing to reduce threats in conversations about risky environmental behaviors (Klonek, Güntner, Lehmann-Willenbrock, & Kauffeld, 2015).

In its first publication, in 1983, the Motivational Interviewing drew attention to its principles, strategies, and pitfalls (Rollnick & Miller, 1995). In its second edition, the authors emphasized the importance of professionals developing some essential skills during the conversation and the PARR (English OARS) concept emerged (Miller & Rollnick, 2002). In 2008, Miller and Rollnick dared in their proposal and published “Motivational Interviewing in Health Care,” broadening the target audience that could benefit from the approach. However, after so many adaptations, through findings of clinical trials, the authors concluded that more changes would be necessary for the real understanding and effectiveness of the Motivational Interviewing and made a new publication in 2013, in which they proposed significant paradigmatic changes and included the concept of the “Spirit” of the Motivational Interviewing which is described as collaborative, evocative and with respect for the autonomy of the client (Figlie, Guimarães, Selma, & Laranjeira, 2015; Miller, Moyers, Arciniega, Ernst, & Forcehimes, 2005; Miller & Rollnick, 2013; Miller, Yahne, Moyers, Martinez, & Pirritano, 2004). The Motivational Interviewing is currently considered a counseling approach and has been gaining space, besides health, in the areas of Education (Snape & Atkinson, 2016), Justice (Coulton et al., 2017), and Social Assistance (Hohman, 2012) and recently in Sports (2019).

Current Surveys

One of the important aspects observed in current research is how much behavior change remains after an intervention based on the Motivational Interviewing. A study of 461 patients who met the criteria for DSM-IV for substance use dependence compared four weeks of structured intervention in the Motivational Interviewing with traditional counseling, and the results showed that there was no difference between groups in the percentage of substance positive urine samples. However, the Motivational Interviewing led to changes in substance use patterns that were maintained over 12 weeks (Ball et al., 2007).

A meta-analysis with 59 randomized studies making a total of 13,342 adult participants diagnosed as substance-dependent according to DSM-IV found that, compared to no treatment, Motivational Interviewing resulted in a significant reduction in the use of substances after intervention (standardized difference of means [SMD] = 0.79, 95% CI 0.48–1.09), as well as in the 12-month follow-up (SMD = 0.15, 95% CI 0.04–0.25). No difference in substance use was observed when the Motivational Interviewing was compared with traditional treatment for substance use disorders (TUSs), other types of treatment, evaluation, and feedback (Smedslund et al., 2011).

Some tests were performed comparing the combination of Motivational Interviewing and treatment intervention for TUSs with a traditional intervention with promising initial results. Another randomized trial of 105 cocaine dependence patients (DSM-IV) compared a detoxification intervention with a Motivational Interviewing intervention. Patients who received the Motivational Interviewing-based detoxification increased their use of coping strategies and were less frequent in cocaine positive urine samples (Stotts, Schmitz, Rhoades, & Grabowski, 2001). Other systematic reviews and meta-analyses have reported that the Motivational Interviewing showed effectiveness in treating substance abuse in adolescents (Tait & Hulse, 2003) and college students (Carey, Scott-Sheldon, Carey, & DeMartini, 2007) and in smoking cessation (Lai, Cahill, Qin, & Tang, 2010).

A differential of the Motivational Interviewing is that with training, it can be effectively performed by doctors, counselors, and other professionals, indicating that the profession seems not to affect the effectiveness of the Motivational Interviewing. Effects are observed in one to four sessions, with a “dose” minimum of about 20 min. It is worth noting that more sessions have been associated more effectively (Rubak, Sandbaek, Lauritzen, & Christensen, 2005).

A review article analyzed the association between professional, patient, and post-intervention behavior in 19 controlled clinical trials using the Motivational Interviewing. Three constructs associated with the outcome of the studies were found, namely the appearance of change statements in patients was associated with better outcomes; the perception of discrepancy by clients was associated with better outcomes; behaviors inconsistent with the Motivational Interviewing by the professional as offering information and advice without permission were associated with worse outcomes (Apodaca & Longabaugh, 2009).

What Is a Motivational Interviewing?

The Motivational Interviewing is a collaborative conversation style aimed at strengthening motivation and commitment to change. Table 18.1 shows the different definitions of the Motivational Interviewing, according to the perception of a layperson, practitioner, and a technical definition (Miller & Rollnick, 2013).

Table 18.1 Definitions of the motivational interviewing
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A very important aspect to take into account is how motivated a person is or not to any kind of behavior change, because in general there is something in human nature that resists change by feeling coerced and forced to do so. Ironically, sometimes the recognition of the other’s right and freedom not to change is what makes change possible. The Motivational Interviewing considers that motivation can be activated, stimulated, and constructed, unlike some approaches that believe that motivation is innate. It was then observed that motivation is a state and not a personality trait, and can thus fluctuate depending on the situation or even be evoked and stimulated at any time by a professional in training (Miller & Rollnick, 2013; Rollnick et al., 2009).

Until today many approaches or treatments believed that they could only help the client if they wanted to, but the Motivational Interviewing has proven otherwise. Because it is an approach that has a specific goal: to solve ambivalence, it is understood as a brief intervention that can be used by a wide range of professionals in different services (Moyers, Houck, Glynn, Hallgren, & Manuel, 2017).

The Motivational Interviewing involves more listening than speaking: the client is expected to speak for most of the intervention (approximately 75% of the time). The idea is for the client to change speaking (from English “Change talking”), replacing the premise: “I have what you need” X “You have what I need and together we will get it” (Miller & Rollnick, 2013). This conversation provides the client with a learning opportunity, with full and free acceptance, without fear of the feelings, values and thoughts that the professional may have. Therefore, the role of the professional is of paramount importance, and he should follow some basic premises that will help him during the Motivational Interviewing practice, presented in Box 18.1.

Box 18.1 Basic Assumptions that will Help the Professional During the Motivational Interviewing Practice

  1. 1.

    Empathy, congruence, collaborative spirit in increasing motivation for change;

  2. 2.

    Adoption of a calm and eliciting style;

  3. 3.

    Consider natural ambivalence. The motivation for change should be elicited in the client and not imposed;

  4. 4.

    Resistance can be reduced or increased through interpersonal interactions. The professional is directive in helping the client to examine and solve the ambivalence;

  5. 5.

    The client-professional relationship must be collaborative and friendly; clients are responsible for their progress. The professional acts as a facilitator in the process, stimulating and supporting the client’s self-efficacy;

  6. 6.

    Abstinence is the safest goal, but not always the best choice, especially with customers in pre-contemplation or contemplation.

The following are presented and described four fundamental concepts for the Motivational Interviewing Clinic.

Ambivalence

The Motivational Interviewing always begins his work with the prospecting of ambivalence, which is defined by the person and not by the professional. Example: a marijuana addict who does not visualize problems with the use of the substance, but accepts to work on his family relationship problems. The interviewer’s posture is to start with the possibilities that the person allows and develops a collaborative conversation, where both build in partnership, the focus of the intervention.

In this context, ambivalence is a mental state in which a person has coexisting and conflicting feelings about something. The difficulties with ambivalence in relation to change are not specific to the use of substances. It is a characteristic of the human condition and taking this condition into account is a fundamental step towards behavior change (Miller & Rollnick, 2013).

We can observe the existence of ambivalence mainly in people who present problems with the use of substances in the search for treatment, because they arrive with fluctuating and conflicting motivations, at the same time they want and do not want to change. This conflict seems to have a special potential to keep people imprisoned, creating great stress, procrastination, and illness (Rollnick et al., 2009).

A professional who listens to a common manifestation of ambivalence such as “I want to stop drinking, but I can’t stop having a beer with my friends,” instead of judging as something wrong, abnormal, unacceptable, and as a sign of little motivation will be able to take this ambivalence into account as expected, acceptable, and understandable and, from then on, raise significant information to be used in the process of change (Arkowitz, Westra, Miller, & Rollnick, 2011).

It is important to stress that working with ambivalence is working with the essence of the problem, with the real motivations that will lead you to maintain or change your behavior (Miller & Rollnick, 2001). Taking into account that motivation is perceived as a state of readiness that can oscillate with time and suffer the influence of interpersonal relationships, it is up to the professional to evoke, extract, or even elicit the motives, the reasons, the desires of the person to change, thus helping to resignify the change itself.

The Motivational Interviewing Process

There is a flow to follow within the Motivational Interviewing, represented by processes that can be viewed in Fig. 18.1.

Fig. 18.1
The diagram describes the Motivational Interviewing Process that follows the flow, engaging, focusing, evoking, and planning.

Four processes in motivational interviewing (Miller & Rollnick, 2013)

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The processes are recursive: one does not end when the next begins. They can flow into each other, overlap, and appeal. This is the confluence of these four processes that best describe the Motivational Interviewing. Since the four processes are sequential and recursive, they are represented as steps on the ladder (Fig. 18.1). Each subsequent process is based on those that were placed before and continue in progression from the previous one, as a foundation. In the course of a conversation, one can also walk up and down the ladder, returning to a previous step that requires renewed attention (Miller & Rollnick, 2013).

Engaging

The initial process takes place with Engagement: if the professional does not engage or even gets involved with a client, the next meetings are unlikely to happen.

Engagement consists in building a therapeutic alliance. When the professional manages to establish a good therapeutic alliance with the client, there is more engagement in the treatment, enabling greater adherence to it. Here, engagement is defined as a process of building a helping relationship, which seeks a solution to the problem pointed out. This relationship is based on mutual respect and trust. The engaged client is not passive to his own change process, he is extremely active within his skills and resources (Miller & Rollnick, 2013).

Focusing

The focus is on developing and maintaining the specific direction of the conversation for change. The client, during the service, may often be involved in a series of events and his tendency may be to focus on the symptoms or the most recent facts that led him there, undervaluing or even ignoring the “cause” factor. It is up to the professional to worry about keeping the focus during the care, so that the conversation is not lost halfway (Miller & Rollnick, 2013). Here it is expected that the ambivalence is defined, because it will be the focus of the intervention.

Evoking

Evoking is the movement of the professional to extract from the person his own feelings concerning the purpose of change. This is the essence of the Motivational Interviewing. All the conclusions or paths to be taken should be a conclusion that the client reaches alone, with the help of the professional and not with his induction. Here, it is up to the professional to take advantage of the client’s own ideas, values, skills, and reasons so that the client discovers how and why he intends to act in a certain way and be truly active in his own process (Miller & Rollnick, 2013).

Planning

Planning is in building the movement of “when” and “how” to change. Taking as a basis the readiness for change, there is a moment when the client lessens his questions and begins to prepare himself for an attitude. At this time, planning is fundamental, as it develops the formulation of a specific action plan and can encourage the client to increase his commitment to change. It is worth pointing out that the planning should not be prescribed but evoked from the client; likewise, it should not be punctual and should always be reviewed—this is why it is the final process (Miller & Rollnick, 2013).

Essential Skills in The Motivational Interviewing

For the conversation to happen in a collaborative way, some skills must be trained and cultivated. Some strategies have been created to facilitate and reinforce this conversation, such as using reflective listening, affirming, summarizing and open-ended questions (PARR) in a ratio of at least 2:1, i.e. with each open-ended question asked it would be interesting to use reflections, affirming reinforcement or even a summary. In this context, the questions are used to a lower proportion as it is expected that all the other strategies can generate more speech in the client, so that the client speaks more than the professional and has a greater openness to be heard, by facilitating communication. In this way, more material emerges for the professional to work and thus strengthen the client as the protagonist of his/her own life. *See below the acronym of PARR (in English OARS): Q: open questions. A: affirm—positive reinforcement. A: reflect. A: summary (Figlie & Payá, 2004; Miller et al., 2004; Miller & Rollnick, 2013).

Asking Open Questions

A good way to start a conversation is to ask questions in a way that encourages the client to talk as much as possible. Open questions are those that cannot be answered easily with a simple word or phrase. Here are some examples of initial questions: Could you talk a little more about this behavior? What did you do to stay abstinent for a week? What has happened since we last met? The main purpose of an open-ended question is to open communication, strengthening and encouraging client autonomy.

Reflective Listening

The Reflective Listening is the main strategy in the Motivational Interviewing and should constitute a substantial proportion during the initial phase of the conversation. The crucial element in reflective listening is how the professional responds to what the client says. Thomas Gordon outlined the model of reflective thinking that connects what the client said with what the professional heard, with the professional’s thinking about what the client wanted to say to finally connect what the client wanted to say with what he actually said (Gordon, 1970). By reflecting, the professional puts himself in the relationship, but at the same time he must be faithful to what the client said. For this reason, the Motivational Interviewing does not work with interpretation and demands from the professional the neutrality to faithfully reflect what the person said.

Offering reflective listening requires training and practice to think reflexively. The process of active listening requires: (a) Careful attention to what the client says; (b) Clear visualization of what has been said; (c) Formulation of the hypothesis concerning the problem, without assumptions or interpretations; (d) Articulating the hypothesis through a non-defensive approach. To evaluate if the reflection made was effective, it is enough to analyze the client’s reaction. If it expresses agreement, it does not present a defensive posture, it opens space for the client to speak more and presents a more relaxed or motivated verbal posture, these are signs that the reflection was effective. On the other hand, if the client begins to warn or threaten, persuade, argue, disagree, judge, criticize or blame, retract, distract, be indulgent or change subjects, these are clear indications that the reflection was not effective and it is up to the professional to reformulate. It is also essential to evaluate the non-verbal communication by receiving the reflection.

There are two types of reflection: simple and complex. The simple reflections are a repetition of what the client said, without adding much information. They have the function of establishing the connection, linking the client to the intervention so that he feels understood. It also serves as a possibility for the professional to better elaborate his listening, before making the complex reflections, or in moments of tension in the conversation.

Example: Customer: I want to stop drinking, but I have a lot of free time lately.

Professional: You’re telling me you want to stop drinking, but you have plenty of free time.

Complex reflections, as the name says, add information to the client’s listening and there are different types of complex reflections (Figlie, 2013; Miller & Rollnick, 2013), described below:

  • Amplified reflection: A very useful approach is to reflect something that the client has said in an exaggerated or amplified way. If the strategy is successful, it will encourage the client to step back and elicit the other side of ambivalence. But beware: an overblown or sarcastic statement may elicit even more resistance.

    Example: Client: I have no problem with marijuana, all my friends smoke. I’ll stop at whatever time I want!

    Professional: So, you mean that you have no problems with marijuana and that your parents’ concern for you is not necessary.

  • Double Reflection: Implies in recognizing what the client said and adding the other side of ambivalence. This can be done by using material that the client has previously offered, even in another session.

    Example: Customer: I am very frustrated.

    Professional: It seems that you are frustrated, but we also know that the fact that you are frustrated makes you seek a relief in the drink.

  • Reflection of feelings: It is the deepest form of reflection, in which emotional elements are incorporated so that the client is aware of his feelings. It is important to point out that this type of reflection is only used when the client’s history is known or when he or she clearly demonstrates their feelings.

    Example: Client: I can’t stop drinking.

    Professional: I understand that this situation discourages you and makes you feel powerless over drinking.

  • Metaphor or paraphrasing: Moves far beyond content to provide a model for understanding, using image figures, popular sayings and metaphors.

    Example: Customer: I can’t stop drinking. I’ve tried everything! Nothing works. Professional: I have the impression that you feel like a dead end.

Affirmation: Positive Reinforcement

The positive reinforcement also has its place in the Motivational Interviewing, being one of its peculiarities. It can be accomplished through appreciation, positive reinforcement, and understanding on the part of the professional, who endorses the person’s qualities, values, skills, and positive strengths. Here are some examples:

  • Your strength of will and determination made you attend the consultation today. Thank you for coming!

  • You’re determined to try and be a better father and recover from this disease.

  • You’ve been under enormous pressure this week. It shows how important your health is to you!

Positive reinforcement is a form of genuine support, encouragement, and true recognition of what is of value in every human being—and not offering mere praise. Positive reinforcement must be genuine.

Summary

Summaries are sets of reflections and statements and can be used to connect the issues that were discussed, demonstrating that you listened to the client, as well as working as a didactic strategy for the client to organize their ideas. Abstracts provide links between the content present and those discussed previously. In the Motivational Interviewing, the summaries can be used at various times during the session: when the client placed several ideas simultaneously and the professional tries to connect them and reflect them to the client for a better understanding; or in transition phases in the processes during the intervention, for an educational purpose. It works as a strong indication for the client that it is being listened to attentively by the professional, generating less resistance and increasing the therapeutic bond.

The Spirit of Motivational Interviewing

The underlying set of mind and heart within which the Motivational Interviewing is practiced is understood as the “Spirit of the Motivational Interviewing” and includes some attitudes of the professional towards his client, such as partnership, acceptance, evocation, and compassion, described in Fig. 18.2 (Figlie et al., 2015; Miller & Rollnick, 2013).

Fig. 18.2
A four-circle Venn diagram describes the Spirit of Motivational Interviewing which includes some attitudes of the professional toward his clients, such as collaboration, acceptance, evocation, and compassion.

The underlying spirit of MI (Adapted by Figlie from Miller & Rollnick, 2013)

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Partnership

The first of the four vital aspects of the spirit involves partnership. It is not something done by an expert to a passive recipient, a teacher to a student, a master to a disciple. In fact, it is not done “for” or “in” someone absolutely. Motivational Interviewing is done “with” a person. It is an active collaboration between specialists. People are the undisputed experts in themselves. No one has been with them longer, or knows them better than themselves. The method involves exploration, interest, and support instead of persuasion or argument, and curiosity on the part of the professional enters into the field of constructive curiosity. Professionals try to create a positive interpersonal atmosphere favorable to change, but not coercive.

Acceptance

For the understanding of MI, acceptance has a strong influence on the works of Carl Rogers and proposes that the professional be interested and value the potential of each individual. Accepting the person does not necessarily mean that the professional approves or endorses the client’s actions, that is, whether the professional approves or disapproves is irrelevant (posture of neutrality). Acceptance consists of the recognition of the absolute worth that the client gives to his/her arguments and reasons, accurate empathy, support for the client’s autonomy, affirmation of speech, and postures in favor of the client’s health and integrity of life. The idea of acceptance is to know how to live with differences, where the professional and client can talk collaboratively, each with their own point of view.

Paradoxically, when the professional accepts the client in the way he presents himself (it is worth remembering that accepting does not imply agreeing), he feels accepted and, therefore, freer and more willing to experience movements of change naturally.

Evocation

Evoke the forces that motivate the person, rather than persuade. Evoking means to remember. Motivation comes from desire, reasons and needs, which means what can make move, engine that causes or determines something. Motivation is an internal resource. Evoking brings the proposal of helping the client to remember his or her own unique elements that can become reasons for a change in behavior.

The professional here tries to evoke the lines of change: any speech of the client that favors the movement towards a specific goal of change, by evoking the desires, reasons, capacities, and abilities of the change, in order to finally make it a necessity for the person.

Compassion

Compassion can be understood as a means of trying to get the professional closer to the person and not to the person’s problem. Observe that there is suffering and a motivation to help. Once the professional is able to have access to the uniqueness of each one, it becomes possible to better understand the individual complexities that hinder behavioral changes. It is an act of getting closer in order to truly help. The authors reinforce the invitation to “put your hand in the mass” WITH the person and not FOR THE person, in order to empower them and count on the active help of the professional.

The concept of compassion, for the Motivational Interviewing, is not in a personal feeling that the professional should develop for his client. For the authors, the compassionate professional is the one who actively promotes the well-being of the other, placing it as a priority before himself. In the most different segments and types of services, the compassionate professional is identified as one who does not see in the client another number, another case, or as a source of income: he sees in the client a unique person, a priority, and full of possibilities, but with some suffering. The final target of each meeting is the client and should not be addressed at any time to satisfy the professional’s own interests.

Final Considerations

The Motivational Interviewing is simple, but it’s not easy. The processes of change involved are natural and, in an intuitive sense, we all know and recognize. Perhaps this is one of the reasons why the Motivational Interviewing was born. However, its practice requires the integration of some quite complex skills that can be improved with practice. Reflective listening alone is a challenge. For someone who is good at this, it may seem easy, as natural as breathing, until you try to do it.

Motivational Interviewing is an approach that has a theoretical basis and is not merely a set of techniques (Lundahl & Burke, 2009). It is a counseling approach with a practical and objective methodology, which can be conducted by any professional, as long as he or she is trained to do so. Faced with this, through tests and adaptations with scientific rigor, the Motivational Interviewing aims, in addition to changing behavior, to add a humanist and constructivist view on changes in risk behaviors.