Miller and Rollnick would probably not agree so much with the title. Both authors maintain that motivation is generated with the person and not unilaterally, acting on a passive subject. However, for marketing purposes of dissemination it is an eye-catching title (and, if you are reading these words, it means that you have somehow managed to capture his attention).
Throughout the history of health, specific knowledge has become more sophisticated in such a way that today it is relatively easy to access the guidelines that help us maintain a life with the greatest possible well-being. However, the fact that a professional suggests that we should stop smoking; tell us a specific diet for diabetes; or recommends the development of activities in accordance with our values to combat depression, is not sufficient to generate adherence to treatment and commitment to change.
Users who go to psychological consultation share a phenomenon: they hope to change something and have not found sufficient tools to achieve it on their own (something inherent to human existence and that happens to all of us, to a greater or lesser extent). At the same time, the fact of going to a consultation reflects a certain interest in being able to change and the hope of achieving said goal. This is where motivation comes into play. This will make it easier for us to resolve the natural ambivalence that exists between the desire to change towards a life more in line with personal values and the inertia of maintaining those behaviors that generate a certain discomfort (and pleasure), avoiding the amount of suffering that modifying them would imply.
Miller and Rollnick have been the authors who have had the greatest impact on addressing this problem. They developed motivational interviewing (MI), defining it as a collaborative conversation style that attempts to reinforce people’s motivation and commitment to change. It is a procedure that can be integrated into various therapeutic orientations, promoting continuity and adherence to treatment.
The EM proposes that the professional adopt a “guiding style”, this being a middle point between a directive position (limited to giving top-down instructions from the role of expert, assuming that the user will simply abide by the professional knowledge in which one is protected) and a companion position (resulting in a rather passive spectator of the change in the subject). It should be noted that MI is not a procedure designed to “install” motivation in someone who has no interest in modifying their behavior. On the contrary, it seeks to evoke in a more clear and directed way the reasons that the subject would have to change.
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There are four key processes that make up EM, which will be addressed in the following sections. Preliminarily I will mention that motivational dialogue focuses on link up with the user, strengthening the therapeutic relationship, focus in delimiting and maintaining a specific direction in conversation, to evoke motivation for change and to plan specific actions to achieve it.
Link
The first process of MS is to link and establish adherence to treatment within a collaborative therapeutic relationship. Bonding is considered the degree to which the client is comfortable and feels like an active participant in the therapeutic process. A bidirectional relationship is suggested in which trust reigns, allowing the user to participate in both the making of the diagnosis and the planning of the treatment.
The therapist will resort to the use of various communication skills that will continue throughout the entire process such as: open questions (inviting reflection and elaboration of responses), statements (explicitly recognizing and commenting on the user’s resources, skills, good intentions and efforts), reflect (paraphrasing what we capture from the user’s speech so that they can tell us if we understood well what they were trying to say), summarize (compiling at the end of the session everything that has been said, and may include material from previous sessions), inform and advise ( prior consent and helping the user to reach their own conclusions).
At the same time, reflective listening will be necessary to convey to the patient a sincere interest in their condition, becoming more involved in their speech than in bureaucratic or protocol issues of the session.
Focus
This second process will be focused on clarifying the client’s goals, helping them discover “yes, why, how and when to change.” It will seek to provide a focus to address by establishing an agreed direction for the consultation itself. For this purpose, the use of meta-conversation will be useful to agree on the agenda to be discussed in the session, facilitating the resolution of obstacles.
The process of focusing provides guidance to the direction of treatment when the objectives seem diffuse (a very common occurrence in situations in which there is ambivalence towards change). It should be mentioned that it is within the ethical principles put forward by the EM not to influence the consultant’s decision. Furthermore, if she considers it appropriate to provide information or advice, the therapist must request permission before providing it, ensuring that the user wants to receive her opinion on the direction of the change.
In short, one of the most frequent difficulties when faced with change is the lack of a clear objective and direction. The therapist must provide the user with the possibility of formulating the target to which it aims, for which it must keep in mind its values and what “a valuable life” is for itself.
To evoke
This third process focuses on resolving ambivalence towards change, evoking and reinforcing the motivation to carry it out. The therapist must recognize and enhance the discourse of change, as well as combat the discourse of permanence and disagreements in the therapeutic alliance.
Ambivalence is considered as the simultaneous presence of contradictory motivations that combine the discourse of change with that of maintenance. To overcome it, the therapist will resort to various strategies such as: open questions that provoke the discourse of change; build confidence that behavior modification is possible; develop decisional balances (explain reasons for change and maintenance), among others. The importance of this process lies in the fact that it generates a discrepancy between the user’s values and the situation in which they currently find themselves. This dissonance must occur in its proper measure, given that it will have to be large enough to generate motivation, but without becoming demoralizing. We must let the user know that not making a change in their behavior is incompatible with certain aspirations, taking care to maintain the hope that said change is possible.
To plan
Finally, this fourth MI process seeks to move from the general intention to a specific action plan and the commitment to carry it out (for the latter, public commitment, social support and self-registration are useful). It is the specific and verbalized manifestation of the actions that the person is willing to carry out to change.
The urgency to plan change is not useful if you do not yet have a good therapeutic relationship, direction or the necessary motivation to carry it out. That is why this is not considered a “last step” of the process, but rather the previous ones must be returned to as many times as necessary.
Without planning, it is possible for the user to seek to alleviate the immediate discomfort by maintaining their behavior. Planning allows us to accommodate the motivation for a specific change within the user’s particular life, anticipating advantages and obstacles that could eventually be faced. It is about managing the best way in which a subject could carry out a change in his or her life.
Why should you train in the use of motivational interviewing?
I would like to conclude this article by mentioning how useful it can be for professionals in various areas to have tools to motivate change in people.
It is an organizing proposal for dialogue that can be applied in numerous fields and theoretical approaches. Its implementation, far from interfering with other protocols or lines of approach, is perfectly applicable as a complement that enriches the bond, direction, motivation and change in particular.
MS provides dialogue guidelines that make it easier for people to live according to their values and goals, its clarification being a great driver for motivation. In addition, its humanistic perspective fosters a collaborative relationship, acceptance, compassion and evocation.
In short, it does not matter in what field you work, or from what theoretical framework you position yourself, as long as your goal is to help someone generate change, MI will be very useful to you.
Bibliographic references:
- Bóveda Fontán, J., Perula De Torres, L. Á., Campiñez Navarro, M., Bosch Fontcuberta, JM, Barragán Brun, N., & Prados Castillejo, JA (2013). Current evidence of motivational interviewing in addressing health problems in primary care. Primary Care, 45(9), 486-495.
- Lizarraga, SD, & Ayarra, M. (2001). Motivational interview. Annals of the Navarra health system. 24, 43-53.
- Lundahl, B., Droubay, B.A., Burke, B., Butters, R.P., Nelford, K., Hardy, C., Keovongsa, K., & Bowles, M. (2019). Motivational interviewing adherence tools: A scoping review investigating content validity. Patient education and counseling.
- Magill, M., Apodaca, TR, Borsari, B., Gaume, J., Hoadley, A., Gordon, REF, Tonigan, JS, & Moyers, T. (2018). A meta-analysis of motivational interviewing process: Technical, relational, and conditional process models of change. Journal of consulting and clinical psychology, 86(2), 140.
- Miller, W.R., & Rollnick, S. (2015). Motivational interviewing: helping people change. Planeta Group (GBS).