run-motivational-interviewing

Run Motivational Interviewing

Resolve ambivalence and elicit intrinsic motivation for change by drawing out the person's own reasons, values, and commitment using the four MI processes.

Why This Is Best Practice

Adopted by: SAMHSA (Substance Abuse and Mental Health Services Administration), WHO alcohol and drug use guidelines, NHS England talking therapies, US Department of Veterans Affairs, over 1,200 randomized controlled trials across health, criminal justice, and education settings.

Impact: Meta-analysis of 119 RCTs found MI outperformed no-treatment controls (d=0.55) and matched active treatments in a quarter of the time (Hettema, Steele & Miller, 2005, JCCP); highest effect sizes in substance use (d=0.77) and HIV risk behavior (d=0.57).

Why best: Activates self-determination theory's autonomy principle — change driven by internal motivation is more durable than externally coerced change. MI systematically builds intrinsic motivation without triggering reactance.

Sources: Miller, W.R. & Rollnick, S. (2013). Motivational Interviewing (3rd ed.). Guilford. Hettema, J., Steele, J. & Miller, W.R. (2005). JCCP, 73(6), 1050-1062. MINT (motivationalinterviewing.org).

Steps

1. Establish the spirit (PACE) — Ground every interaction in Partnership (collaborative, not expert-to-patient), Acceptance (unconditional positive regard + autonomy support), Compassion (prioritize the person's wellbeing), and Evocation (draw out, don't install motivation). Spirit precedes all technique.

2. Engage: build rapport and trust — Use OARS in engagement mode: Open questions, Affirming strengths, Reflecting content and feeling, Summarizing. Do not mention change yet. The goal is for the person to feel safe and understood.

3. Focus: identify a change target — Collaboratively narrow the conversation to a specific change domain. In some contexts this is given (clinical setting); in others it must be negotiated. Ask: "What would you most like to talk about today?"

4. Evoke: elicit change talk — Draw out DARN-CAT change talk:

   • Desire ("I want to..."), Ability ("I could..."), Reasons ("The good thing about changing would be..."), Need ("I have to...") — preparatory change talk
   • Commitment ("I will..."), Activation ("I'm ready to..."), Taking steps ("I've already...") — mobilizing change talk Use evocative questions: "What worries you most about staying the same?" "What would be the best thing about making this change?"

5. Explore ambivalence with decisional balance — When ambivalence is strong, explore both sides without pushing: "What are the good things about [current behavior]? What are the less good things?" Acknowledge both sides fully before any emphasis on change side.

6. Reflect change talk selectively — Reflect change talk statements with slightly amplified attention. Reflect sustain talk (reasons not to change) neutrally and briefly. Do not argue against sustain talk.

7. Roll with resistance (discord) — When the person pushes back, do not confront. Use reflection, reframe, or shift focus: "Sounds like you're not ready to think about that right now — what would you like to focus on?" Discord is a signal to soften approach, not press harder.

8. Assess readiness with importance and confidence rulers — Ask: "On a scale of 0-10, how important is this change to you? How confident are you that you could do it if you decided to?" Follow up: "Why [number] and not lower?" This elicits self-generated change talk.

9. Plan: build a change plan collaboratively — When the person moves to mobilizing change talk, shift to planning. Ask: "What do you think you might do? What would a next step look like?" Do not impose the plan; evoke it.

10. Strengthen commitment and elicit SMART intention — Ask for a specific commitment statement: "What specifically are you willing to do before we talk next?" Summarize the plan including the person's own words and reasons.

Rules

• Never argue, confront, or persuade — any attempt to push change triggers reactance and increases sustain talk; the practitioner's job is to create space, not install motivation.
• Track the ratio: change talk should increase over the session; if sustain talk dominates, soften approach, re-engage, or return to exploring ambivalence.
• Affirm genuine strengths only — generic praise ("You're doing great!") is transparent and undermines credibility; specific behavioral affirmations work ("You came back even after a hard week — that's persistence.").
• Autonomy support is non-negotiable — explicitly honor the person's right to choose not to change, including when you disagree with that choice.
• Do not move to planning until mobilizing change talk (Commitment, Activation, Taking steps) is present — premature planning into ambivalence backfires.

Common Mistakes

• The righting reflex — the practitioner's instinct to fix, educate, or persuade activates client defensiveness and is the single most common MI violation.
• Reflecting sustain talk with equal weight to change talk — symmetrical reflection does not help; change talk needs amplified reflection, sustain talk needs brief neutral acknowledgment.
• Premature focus on planning — jumping to action plans before ambivalence is resolved produces plans the person doesn't follow through on.
• Fake affirmation — saying "Good job!" to everything signals inattention and patronizes the person; affirmations must be specific and genuine.

When NOT to Use

• Situations where the person has already made a firm decision and wants implementation support — MI is for ambivalence, not execution.
• Acute crisis requiring directive intervention (psychosis, medical emergency, immediate safety risk).
• When the practitioner is too invested in a specific outcome — MI requires genuine acceptance of the person's autonomy, which is impossible if the practitioner cannot tolerate non-change.
• Contexts where the person's goal itself is harmful to others (do not evoke motivation for harmful behavior).