On the go? Listen to the audio version of the article here:

If you’re working in the helping professions like social work, addiction counseling, or the medical field, you’ve likely come across motivational interviewing and wondered how it works. If you’re not familiar, motivational interviewing is a collaborative counseling style, designed to evoke a person’s motivation for change.

Several studies confirm the efficacy of motivational interviewing, but many practitioners find it challenging to apply this technique and don’t understand how it works. Unlike cognitive-behavioral therapy, motivational interviewing appears much more passive.

On the surface, motivational interviewing is mostly invisible, yet it can powerfully facilitate change. Although motivational interviewing works, understanding how it works is just as important. It is not merely a set of techniques. Instead, it is a way of being with a client that facilitates change.

So how does motivational interviewing work?

Motivational interviewing works by supporting a client’s sense of intrinsic motivation, self-efficacy, and a sense of empathic connection to the counselor. Each of these factors leads to increased motivation to change.

Let’s take a look at each of these areas to understand more fully how motivational interviewing works.

Motivational Interviewing Builds Intrinsic Motivation

As described in my article on What Causes People to Change, intrinsic motivation is a leading cause of long term sustainable change.

Intrinsic motivation is the internal desire to make a change as opposed to extrinsic motivation, where external pressures or rewards cause change.

An example of intrinsic motivation would be having a deep enjoyment of playing a musical instrument. You feel drawn to practicing and enjoy the process.

If someone were to start paying you to practice (extrinsic motivation), then had authority over how and when you practiced, it could take away your intrinsic motivation, leading to less desire to practice in the long-term.

Motivational interviewing is designed to facilitate intrinsic motivation. Let’s take a closer look at how it does this.

Collaboration Rather Than Confrontation 

Motivational interviewing emphasizes collaboration because it works. Collaboration works because it helps build intrinsic motivation.

Consider the classic example of your medical doctor telling you that you’ll need to lose weight. How many people can attribute significant life changes to this type of advice? This approach is not collaborative since it is advice from authority.

The medical field generally operates from the model of expert authority, giving direction to a passive patient. Expert advice and threats of health consequences are a form of extrinsic motivation, which is unsustainable in the long-term.

Motivational interviewing emphasizes approaching clients from a collaborative perspective, encouraging them to be active participants in their treatment plan, not merely a passive recipient.

Open-ended Questions 

Open-ended questions are powerful tools for facilitating collaboration. These consist of questions that can’t be simply answered with “yes” or “no.”

Most open-ended questions generally start with the word “what.” For example, “what is the issue you want to discuss?”

These types of questions facilitate collaboration by putting the other person in an active position. Their participation is encouraged by the need to further elaborate their reasons for seeking treatment, what they want out of the working relationship, and what they’ve been trying so far that hasn’t been working.

Developing Discrepancy 

This technique works to build intrinsic motivation by highlighting the gap between someone’s actions and their values.

As you ask someone what they want and what they’ve been doing up to this point, a gap between their actions and values might emerge. For example, someone might value community, yet they are self-isolating due to fear of social rejection.

Collaboratively pointing out this gap might consist of asking a series of open-ended questions about what they value and what they are doing, then simply reflecting back, “…on one hand you value community, but on the other, it looks like something is stopping you from socially engaging.”

Gently bringing someone’s attention to the gap between their actions and their values builds intrinsic motivation since it is highlighting their own values rather than externally imposed values.

Motivational Interviewing Builds Self-efficacy

Self-efficacy is the perception of one’s abilities to effectively handle a situation or overcome an obstacle.

Research on self-efficacy demonstrates the critical role it plays in motivation. Persons with high self-efficacy are more likely to maintain high motivation for goal attainment, especially when these goals are self-directed.

Motivational interviewing works by facilitating high self-efficacy. It does this through supporting client autonomy, encouraging “change talk,” and through a collaborative approach to treatment planning.

Supporting Autonomy 

Supporting autonomy means maintaining the independence of the client. Rather than taking control, directing the conversation, and doing things for a client, supporting their autonomy means keeping them in control.

Although it may be tempting to take control and start doing things for someone, this takes away their sense of control and accomplishment.

When someone accumulates small wins over time, they begin to gain a sense of self-efficacy. This increasing sense of competence builds confidence in one’s abilities to effectively cope with future challenges.

Facilitating Change Talk 

Change talk can be defined as positive statements about change. The amount of change talk by a client generally predicts the likelihood of change.

The opposite of change talk is sustain talk. These are negative statements about change and language focused on being stuck.

Motivational interviewing works by amplifying the amount of change talk through focusing on these positive areas of competence and hope, rather than unnecessarily staying focused on what is not working. This is how evoking change talk builds self-efficacy.

Collaborative planning

Collaborative planning means being like a travel agent. This means working with the person to find out where they want to go and how they want to get there.

Travel agents work with you in a partnership rather than merely telling you where to go. Also, once you’re on the trip, the travel agent can be consulted, but it is not their job to go with you and carry your luggage.

A collaborative approach to treatment planning works by building self-efficacy. Making progress on a plan you create for yourself builds confidence in your ability to set goals and follow through.

Motivational Interviewing Builds Empathic Connection

Empathy involves deeply listening, showing an understanding of the other person’s perspective. Beyond sympathy, empathy requires fully being with the client and holding space for whatever they need to discuss.

The therapeutic relationship is one of the most important aspects of counseling, and empathy is fundamental to a strong therapeutic relationship.

Accepting Clients Where They Are

Acceptance is a core foundation of motivational interviewing. It means accepting a person where they are, recognizing their worth as a human being. We may not like every characteristic or behavior, but acceptance goes beyond these things.

Acceptance requires seeing a person’s common humanity, recognizing there are likely many reasons why they are in their current position.

Acceptance does not mean accepting bad behavior. Instead, it means treating someone with dignity while setting boundaries if lines are crossed.

Acceptance works to build an empathic connection since it allows you to see past surface characteristics so you can see the whole person in front of you.

Rolling with Resistance 

Rolling with resistance works to build empathy, increasing the likelihood of change.

Rolling with resistance is like verbal judo. It means rolling with confrontational momentum rather than trying to stop the momentum through counter-confrontation. This means avoiding direct confrontation through argumentation.

If you think someone is wrong about something, does direct confrontation simply change their mind? If this approach worked, it would save the world many Facebook flame battles and frustrating political conversations over the holidays.

So how do you roll with resistance? When you feel like arguing with someone, hold back and keep listening… then listen some more. As Stephen Covey said, “Seek first to understand, then to be understood.”

How do you listen effectively, beyond merely not talking? The answer is reflective listening, one of the most important parts of motivational interviewing.

Reflective Listening

Reflective listening makes up the largest part of motivational interviewing and generally comprises around 75% of counselor responses.

Reflective listening works by building empathy, showing you understand, rather than simply telling someone you understand.

The most powerful form of reflection is the “complex reflection.” This consists of continuing the other person’s sentences or paragraphs by guessing what they mean. The key to this technique is that the dialogue should flow as if it were a single person speaking.

Example:
Client: “When I come to the casino, I find it difficult to control my spending.”
You: “the games are so engaging, and you lose track of time.”
Client: “yeah, and the other day I was here for six hours, and it only felt like one!”
You: “and before you know it, you’re spending a lot more money than you planned.”

Reflective listening is also a vital tool for rolling with resistance, collaborative planning, supporting client autonomy, and facilitating further change talk.

Conclusion 

Motivational interviewing works because it uses various techniques and relational approaches that maximize intrinsic motivation, self-efficacy, and a sense of empathic connection. Each of these areas is associated with increased motivation for change.

If you are interested in further exploring how to use motivational interviewing, the British Medical Journal has a great free online course that gives practical video examples.

Hopefully, this article helped lay a foundation for understanding how motivational interviewing works and why it is an essential tool for conversations about change.