Motivational interviewing is on the rise globally and in Australia, especially in our capital cities- as many of our modern day occupations involve supporting and helping people to change- including healthcare, sports-coaching, social work, counselling, drugs and alcohol work and many others. It sounds rather glib: motivational interviewing- a bit like motivational speaking (I’m sorry that’s an insult to motivational speakers, I’m sure you are very motivational and valid etc…) how about snake oil salesmanship?
Perhaps the one (and only) area where I disagree with the ‘architects’ of MI (Professors Bill Miller and Steve Rollnick) is the name itself. Motivational Interviewing is not a technique, a trick, or in any way glib or gimmicky but rather- it is a complete form of psychotherapy, a counselling approach which has been successfully adapted to many health and social care settings and is now considered, in these areas, as a ‘frontline approach’ especially in the US and Europe. In Perth and more widely across Australia, we are seeing more and more professions engage in training on Motivational Interviewing and putting it into practice to assist their clients. MI is based upon a foundation of the scientific work of one of the founding fathers of psychotherapy: Carl Rogers. Rogers’ work, beginning in the 1950’s, in treating patients became the basis for client-centred counselling which has massively influenced the world of helping psychology- over the intervening 70 years and motivational interviewing stems directly from this work.
The concept of MI was first articulated by Miller and Rollnick when they met on sabbatical in Sydney. Miller’s thoughts were developed earlier when he was on a different sabbatical- academics love their sabbaticals- and a good job too- as it was in Norway where Miller was questioned by interns about the way he counselled people, interns asked questions such as when a client says x- why do you respond by doing Y? In this way Miller started to pick apart why he did what he did and how it was so effective.
My latest google scholar search reveals 211,000 results for the phrase: ’motivational interviewing’ in terms of answering does it work? The answer is typical of a scientist: yes and no and maybe- a problem being that many studies are produced without any check of what quality the motivational interviewing- that was delivered- actually was…and naturally we need to know how ‘good’, clear and bona fide the MI actually was- otherwise it is akin to trying to study aspirin’s effects on pain relief without actually knowing how much (if any) aspirin was in the pill administered to the people in the study.
So the MI needs to be done well to verify its effectiveness and subsequently the quality of training delivery needs to be good. Even though MI is not regulated (in the same way medicine is for example) it does have a good supportive foundation in MINT (The Motivational Interviewing Network of Trainers) where the essential criteria is that trainers prove their own ability in applying the approach of MI with clients before they are accepted to train as trainers.
That being said many randomised control trials, systematic reviews and research papers produced on MI suggest positive effects. A suspicion to be confirmed is that this ‘effect’ may be strengthened when good quality MI (referred to as ‘treatment fidelity’) is delivered to clients. This means- someone independently confirming that what was delivered actually was MI- rather than someone reading a book and then simply stating: ’we do MI’, ‘had an MI style approach’ or used ‘MI techniques’ (remember these are not techniques- or at least not just techniques). One of my trainees (a general practitioner) recently referred to MI as Jedi mind tricks. Someone setting out to help another perform, achieve, recover is not, however, a trickster- rather they have at their core a genuine desire to help the client. If that’s not your genuine desire this is not for you.
My background (Public Health, Nutrition, Sport and exercise science) set me up to give all kinds of advice to my clients/patients- but I guess at the back of my mind, I knew, like many other health practitioners, that advice and messages are very often not just unhelpful in changing people’s behaviour but actually can be counter productive… Indeed, Miller and colleagues found that in an alcohol research programme (the drinker’s check up project) the people who were given advice, messages and instructions actually fared worse than people who were simply asked to keep a diary…
In a mirror to this I found that my overweight clients’ success from keeping a diet diary were not because I could subsequently analyse their diets and tell them where they were going wrong- but actually it was from them becoming aware of what they were doing and then making their own decisions about what might/could/should change… So just leave people alone and they’ll fix themselves? Well no, not quite- but this does tell us that people are experts on themselves- you know more about yourself than I do- but I can help steer and guide in a skillful manner and together we will come up with answers which work for you- that is MI.
That skillful manner- can be learnt by anyone wishing to develop effective behaviour change skills for working with their clients. Typically a day’s introduction is built upon with practice and then intermediate and advanced level training workshops are interspersed with coaching and feedback which really helps practitioners move their skills onto a higher level.
This is a common question with so many specialist areas having behaviour change as part of the job- so it is safe to say it works for a very wide range of areas- it is not so much the topic of change (e.g. alcohol problems versus sports coaching outcomes) It is more about the fact that change is sought and especially, in my experience, where that change is difficult to achieve. MI comes into its own particularly when people are ambivalent- when they feel more than one way about a behaviour e.g: ‘I know I should lose some weight, but I really like drinking wine whilst watching TV’ is a typical ambivalent feeling about weight management. MI helps clients to resolve their ambivalence by following a clear approach to acknowledging that person as an expert on themselves and then guiding them towards positive change. Typically, when going well, the MI professional will facilitate a conversation where a client will present the arguments for making changes; (‘these are not the droids you are looking for’) whereas a confronting, information driven approach often results in the client arguing against change. People often do this (argue against) when they are being lectured to, or presented with ‘evidence’ as to why they should do something, we like autonomy and don’t like being told what to do- MI avoids this by teaching us to skillfully stay onside with the client.
This is not a research trial per se but my own early case studies using MI were on: a) a client with an eating disorder, b) a client with concerns about drinking and c) a client struggling to control her weight. In an effort to test MI on my clients I trained, initially via a series of workshops, which nowadays I deliver to other professionals, then I had some coaching to help me gain ‘treatment fidelity’ -confirmation that what I was doing actually was verifiable as MI- The results were really encouraging, my drinker started her feedback with: ‘What kind of magic is this? I am drinking less, am in control where before I was not…’ the eating disorder client said: ‘this problem is not completely solved, I just know now that I have more control than I did before, I do more things which are successful…’ and the weight management client lost a very significant amount of weight, but more importantly, in her view, was focused on ‘the things which will allow me to keep this (various behaviours) going long-term’. They were just my early observations and all with clients who were definitely ambivalent about their behaviours.
So what would I call it? It doesn’t really matter- I will put my annoyance to one side and call it what it is- MI- I care more that it helps me support my clients to change their behaviour and supports my colleagues in gaining proficiency in delivering effective health and performance behaviour change outcomes.
Dr Trevor Simper
Trevor is an MI trainer, coach, researcher and University lecturer and delivers Motivational Interviewing Training in Perth, for beginner to advanced level MI practitioners via workshops and coaching . If you would like to read more about Trevor and his workshops on Essemy click this link.