Many individuals who enter therapy, for issues like substance abuse, behaviors that have led to legal problems or relationship issues, and behaviors that require individuals to make significant changes in their attitudes or beliefs, are often not fully ready to accept the fact that they are the ones who need to change. An important aspect contributing to the effectiveness of any type of therapy is the motivation of the person in therapy to actually participate and to make changes.
Motivational Interviewing (MI) is a technique developed to ascertain where clients in therapy stand regarding their need to change, and to help them make progress in therapy by helping them to see the need for change and understand how change occurs.
A Very Brief History of MI
MI was developed as a result of frustrations therapists experienced in treating individuals with alcohol use disorders. The initial concepts of MI were refined and later published in a series of several books and articles. MI tends to be goal-directed and focused on helping individuals to consider making changes as opposed to simply reflecting their feelings. As a result, MI has been incorporated into many different therapeutic paradigms and theoretical approaches to treatment.
Stages of Change Model of MI
Perhaps the most recognized contribution of Motivational Interviewing is the transtheoretical outline of the process of change that occurs in individuals. MI does not automatically assume that everyone who is entering therapy is at the same point in their understanding of their need to change or in their progress towards experiencing positive changes. MI proposes that the process of change occurs along a series of steps. The therapist should consider where the individual is regarding this process and adjust the treatment according to clients’ standings regarding their need to change or their progress toward change.
The steps of change according to MI are:
- Stage I: Precontemplation: At this stage, individuals do not see the need to change their behavior. They may or may not be experiencing negative effects from their use of substances or other issues, such as depression, etc.. Regardless of how these issues are affecting their lives, they have not yet seriously considered changing their behavior and have little interest in changing the behavior. Many individuals entering substance abuse treatment programs are at this stage of change. Often, therapists and others consider them to be “in denial” regarding their need to change. In MI, therapists “roll” with denial, point out inconsistencies in beliefs and behaviors, and let clients discover their need to change instead of making accusations and directly confronting them.
- Stage II: Contemplation: At this point in the process, clients may realize that their behavior is problematic; however, they have made no commitment to changing. Clients may be open to considering the need to change or may even want to change, but have made no formal moves toward committing to change or making a change in their behavior. This is also stage that many individuals with substance abuse issues who first enter treatment find themselves. They are beginning to see that they have a problem, but are not sure whether or not they need to actually make a change (the “I can control it,” or “I was just unlucky and got caught,” stances). They may be thinking about the possibility of changing, but are not committed to taking action.
- Stage III: Preparation: At this point, individuals realize that they must make a change and are beginning to evaluate how to approach making a change in their behavior. Here, clients begin to think of the types of actions that are open to them in order to decrease the negative effects of whatever behavior is occurring that is causing them problems. They are getting ready to implement changes. Individuals in this stage begin to embrace the idea that the responsibility for change lies with them.
- Stage IV: Action: Clients are engaging in real efforts to make a change. These efforts can include nearly anything, such as attempting to cut back on their substance use, seeking out formal help such as therapy, going to 12-Step groups, and so forth. There is no requirement that the person stick to any particular action, but instead in this stage, the person is putting forth a real effort to change behavior. Individuals with substance use disorders may linger in this stage for quite some time.
- Stage V: Maintenance: In this stage, people have been relatively successful at changing their behavior and are now attempting to maintain their new skills and to avoid going back to their old ways. They may have tried several different methods in the action stage and experienced a series of successes and failures, or they may have just tried one particular approach and are attempting to maintain positive results from that approach.
- Stage VI: Termination: In this stage, people have adopted the behavioral changes and approach life by maintaining the positive changes that they have previously made. They are able to address challenges and obstacles that threaten the new changes and continue on. Termination does not mean that they give up or quit, but that the process of change is relatively complete, and clients move forward maintaining their new behaviors and adding to them.
One thing to understand regarding the MI stages of change model is that for most people this is not a linear process that simply occurs in order, with one stage after another and the person is finished. Many individuals will experience setbacks, failures, and the need to restart. For example, someone in the action stage may attempt to change behavior and be successful at first, but relapse and need to start over again at a previous stage, such as precontemplation or contemplation. Individuals in the termination stage may experience a relapse and need to start all over again. People in any stage of change may experience difficulties and need to start over again at an earlier stage.
Therapists who follow process of Motivational Interviewing and are invested in the stages of change model are encouraged to recognize where clients lie on the continuum of change and then develop a therapeutic approach that assists them in either recognizing their need to change (e.g. someone in the precontemplation or contemplation stage), assist them in making efficient and functional changes (e.g., someone in the action stage), or help them avoid relapsing (e.g., someone in the action, maintenance, or termination stages). Individuals who are attempting to change their substance abuse may go through this chain of events several different times, or experience setbacks and repeat earlier stages many times before they finally experience some level of success. MI is the process of understanding where clients are on the model of change and then assisting them to move forward through the process of change with as few setbacks as possible.
Therapist Skills
In order to assist individuals, therapists using the stages of change model are required to develop some specific skills. These include being able to listen to clients extremely well, understand exactly what individuals are communicating, develop a strong sense of empathy, and provide organized and comprehensive positive feedback affirmations to individuals in therapy. Therapists also need to have a fairly resistant constitution as the very nature of clients in this therapy results in a number of trial-and-error approaches and resistance to actually changing.
MI is an approach that can be incorporated into a number of different applications. Typically, it has been incorporated into:
- Many cognitive and behavioral treatments
- Behavioral therapy, such as exposure therapies and systematic desensitization
- Group and family therapies
- Other therapies for substance abuse
- Treatment for problem gambling and other types of behavioral addictions
- Relapse prevention programs
- Treatments for certain psychological disorders, such as personality disorders
- Treatment of many medical conditions, such as HIV
- Practical applications in business and education
Is MI Effective?
Therapists and other professionals use MI as a process to assist individuals in need of change. The research on MI regarding its effectiveness in helping individuals with a number of different issues is generally positive. For instance, a meta-analysis reported in the British Journal of Medical Practice indicated that of all the studies reviewed, about 80 percent of them found positive effects for MI, and that individuals using the principles of MI were more effective in inducing changes than those given traditional. Meta-analysis is a statistical technique that combines the effects of many different studies and is a better method of determining if a particular treatment demonstrates overall effectiveness than any single study.
Since Motivational Interviewing can be incorporated into many different types of treatment in different types of therapies, it can be useful in assisting individuals who are having trouble recognizing the need to change or to help individuals who are stuck deciding what types of changes they need to make. However, other specific techniques, such as Cognitive Behavioral Therapy, need to be combined with the process of MI to assist individuals in actually making positive changes.