What is the activity?
Motivational interviewing (MI) is a tool for helping people to change - it is used to promote (or elicit) behaviour change by supporting people to explore and resolve their own conflicting feelings (ambivalence) about changing their behaviour. It uses a "guiding style" to engage with people, clarify their strengths and aspirations, evoke their own motivations for change, and promote autonomy of decision making.
The most recent definition of Motivational Interviewing (Miller & Rollnick, 2009) is: “a collaborative, person-centred form of guiding to elicit and strengthen motivation for change." Motivational Interviewing (MI) is an empathic counselling approach that is considered to be both client-centred and directive.
MI departs from traditional (Rogerian) client-centred therapy through this use of direction, in which practitioners try to influence people to make changes in behaviour, rather than having them explore their feelings or actions. MI is considered directive in that it uses reflective listening techniques to guide people towards more healthy behaviours (using a condom or getting tested for HIV, for example) and away from risky behaviours, though this should occur in the context of their own values and concerns.
MI focuses on exploring and resolving conflicting feelings (ambivalence) about changing behaviours and supporting existing motivations to change. It should consider the individuals environment, opportunities, barriers and motives for change. It is widely used in the context of behaviour change with regard to physical activity / exercise, diet, rehabilitation, smoking, alcohol and drug use. There is substantial evidence of its efficacy in relation to problematic alcohol (and drug) consumption but far less evidence in other health areas.
The MI approach is based upon four key principles:
- Express empathy. Practitioners share with clients their understanding of the persons perspective.
- Develop discrepancy. Practitioners help people appreciate the value of change by exploring the discrepancy between how they want their lives to be and how they currently are.
- Roll with resistance. Practitioners accept a person’s reluctance to alter their behaviour as natural rather than pathological and are not confrontational about it.
- Support self-efficacy. Practitioners explicitly embrace client autonomy (even when they choose to not alter their behaviour) but hope to move them towards change.
The MI style is collaborative requiring distinct techniques and skills (Skills Tip Sheet). Open questions, Affirmation, Reflective listening, and Summary reflections (OARS) are the basic techniques and skills that practitioners are encouraged to use “early and often” in MI. However, MI is not defined by the techniques applied but by its spirit as a facilitative or guiding style.
Strengths and limitations
MI is a useful way to work with people who are not yet thinking about change or have conflicting feelings (ambivalence) about it. These are individuals in the precontemplative or contemplative stages according to The Transtheoretical Model, commonly known as the Stages of Change Model (Prochaska and DiClemente, 1984). This model can be a useful way to consider a person’s stage of readiness for behaviour change.
The MI approach is strengths-based. It elicits peoples' motivation to change, rather than attempting to convince them to follow a prescribed course of action. Unlike other approaches that can increase people's resistance to change, MI is considered effective in reducing resistance and enhancing willingness to change. While using client-centred techniques to build trust and reduce resistance, the practitioner can focus on building readiness to change.
In the UK, MI is one technique taught to healthcare staff in HIV and STI clinics. NICE have also recommended it as a behavioural intervention for a number of populations, such as drug-using adolescents and it is mentioned as a useful intervention for gay men at risk of HIV in the evidence supporting the NICE guidelines (2007) on the Prevention of sexually transmitted infections and under 18 conceptions.
In the context of HIV prevention, dIstinguishing MI from extended 1-2-1 information and advice which applies MI techniques is not straightforward. Being trained in MI does not make all your interventions MI; and extended (or assertive) 1-2-1 information and advice does not automatically become MI. MI requires specific listening and reflecting techniques but is often said not to be defined by the techniques applied but by its spirit as a facilitative or guiding style. Interventions that have a single unitary aim (getting an HIV test; or always using a condom, for example) might still be considered MI, if the practitioner does not try to impose this health behaviour change on the recipient, irrespective of their circumstances or motivations.
A meta-analysis (Berg et al. 2011) of the impact of MI - and other behavioural interventions adapting the principles and techniques of MI - on HIV-risk behaviours of MSM found little evidence of efficacy. In the meta-analysis, improvements in outcomes included a 6% reduction in unprotected anal intercourse with casual partners, a 2% reduction with primary partners, and a 6% increase in condom use. There was a reduction of about a third in the numbers of sexual partners over the short-term but this was not statistically significant. The only MI outcome that remained significant was alcohol use. MI more than halved alcohol consumption in the short-term though this lost significance over longer-term follow-up.
Where does it happen?
MI interventions are usually delivered face-to-face by practitioners with appropriate training and experience. An MI session can last anything up to an hour, and will usually be part of an ongoing dialogue over more than one session. There is no definitive rule on the duration of an MI session, nor the number of sessions that need to occur. However, a single intervention of less than 30 minutes is very unlikely to utilise all the key techniques of MI, within the context of its over-arching spirit.
MI usually occurs in the ofﬁces of service providers (including NHS and voluntary sector services) but could occur in commercial or community venues (such as pubs, clubs, or shops). Sufficient privacy to have a frank and open exchange of views is essential. Staff delivering repeated MI sessions to the same person will require the time and resources to keep adequate notes on sessions, which must be handled in accordance with the Data Protection Act 1998.
Frequently delivered alongside ...
Issues to consider
MI will appeal to health promoters who value autonomy and self-determination (You decide approaches) in the people they seek to support. However, enthusiasm for MI as an approach plus some knowledge of MI techniques is not sufficient to become a proficient practitioner. Adequate MI requires a wide range of skills and ongoing training, practice and supervision, like most psychological interventions.
MI was originally developed for use in specialised drug and alcohol treatment settings by highly trained addiction counsellors. In these contexts the norm was that the client received multiple MI sessions of significant duration. In the thirty years since its inception MI and various adaptions of it have been applied in health areas including smoking cessation, HIV prevention, diet and exercise, treatment adherence and gambling. In some of these contexts it is not uncommon to have just one brief session of MI. To highlight the differences between MI and its less intense derivatives, two alternate kinds of behaviour change interventions have been described by the originators of MI (Miller and Rollnick 2002).
- Brief advice (BA) is their phrase for short interventions (5-15 minutes) that are often opportunistic and one-off rather than sought by a person who recognises the need for support to make changes in their behaviour. Their description is functionally identical to our description of 1-2-1 information and advice. The goal is described as encouraging the person to start thinking about changing their behaviour, with some recognition that the advice element is likely to be more directive and less client-centred than MI usually is.
- Behavioural change counselling (BCC) is described as the next step. It requires more time (up to 30 minutes) though it can still occur once only. It can take place with people that were not seeking support and with people who were actively seeking behaviour change support. It has a greater focus on identifying the person's own goals and building on their motivation to change behaviours than Brief advice (or in our terms, 1-2-1 information and advice). Practitioners will require more training than those delivering 1-2-1 information and advice especially with regard to judging readiness to change and the capacity to express empathy.
MI training is available in a range of formats including online distance learning and webinars (see www.motivationalinterview.org), and from half-day courses to 5-day skills based workshops. Those who have received extensive training in counselling and / or psychology will probably have already developed some client-led counselling skills, and may require less MI training. HIV prevention workers and others with a more public health background will require more training and practice to master MI, and may need to shift their philosophical orientation. For many HIV health promoters the time required to develop the skills required to deliver interventions that fully reflect the spirit of MI, may not be practicable. It may be more appropriate to train health promoters used to giving 1-2-1 information and advice to use more straightforward behavioural change counselling techniques (BCC).
Aims and outcomes
Predictably the aims and intended outcomes of MI tend to focus on motivation to increase HIV precautions (such as using condoms or testing for HIV) and reduce HIV transmission risk behaviours. The list below offers some examples of likely aims but is not remotely exhaustive.
- Increased motivation for STI screening and HIV testing (see associated choice and potential aims associated with HIV testing knowledge; STI knowledge; and the testing opportunities and skills required).
- Increased motivation to avoid HIV exposure and transmission (see associated choice and some of the opportunities and resources and skills needed).
- Increased control over involvement in HIV exposure and transmission (see associated choices such as declining or deferring a new sexual partner).
- Increased conﬁdence to openly discuss sex, sexuality, and sexual health with partners and in social networks, including the skills to discuss sex with partners and decline or defer sexual contact having new sexual partners.
Monitoring and evaluation
MI interventions can aim to meet an extensive range of needs tailored to individual service users, but the outcomes may not be immediately apparent, or may have a very indirect relationship to HIV prevention.
In terms of evaluation, questionnaires and interviews with people who use and do not use the service can help to assess perceptions of the service and its means of recruitment, accessibilty challenges, and to identify key areas for changing methods in delivery.
Reviews of anonymised case notes can be used to assess short-term changes noted by MI practitioners. However, longer-term follow-up - through repeated interviewing - is perhaps the best way to evaluate longer-term beneﬁts to individuals, couples and families.
Page last updated: 30 July 2013