Why motivational interviewing doesnt work

Metrics details. Motivational Interviewing MI , a counseling style initially used to treat addictions, increasingly has been used in health care and public health settings. This manuscript provides an overview of MI, including its theoretical origins and core clinical strategies.

We also address similarities and differences with Self-Determination Theory. MI has been defined as person-centered method of guiding to elicit and strengthen personal motivation for change. Core clinical strategies include, e. MI encourages individuals to work through their ambivalence about behavior change and to explore discrepancy between their current behavior and broader life goals and values.

A key challenge for MI practitioners is deciding when and how to transition from building motivation to the goal setting and planning phases of counseling.

To address this, we present a new three-phase model that provides a framework for moving from WHY to HOW; from building motivation to more action oriented counseling, within a patient centered framework. Motivational Interviewing MI is a counseling style initially used to treat addictions [ 1 — 5 ]. Its efficacy has been demonstrated in numerous randomized trials across a range of conditions and settings [ 5 — 8 ].

Over the past 15 years, there have been considerable efforts to adapt and test MI across various chronic disease behaviors [ 7 , 9 — 21 ]. This article provides an overview of MI and its philosophic orientation and essential strategies, with an emphasis on its application to health promotion and chronic disease prevention. Because many practitioners find it difficult deciding when and how to transition from building motivation to the goal setting and planning phases of counseling, we present a new three-phase model that provides a framework for helping clinicians transition from the WHY to HOW phase; from building motivation to more action oriented counseling.

Further, we discuss possible connections between elements of the three phase MI model and Self-Determination Theory.

MI is an egalitarian, empathetic "way of being". It is a communication style that uses specific techniques and strategies such as reflective listening, shared decision-making, and eliciting change talk. Recently it has been defined as a "person-centered method of guiding to elicit and strengthen personal motivation for change " [ 22 ].

An effective MI practitioner is able to strategically balance the need to "comfort the afflicted" and "afflict the comfortable"; to balance the expression of empathy with the need to build sufficient discrepancy to stimulate change. One goal of MI is to assist individuals to work through their ambivalence or resistance about behavior change. MI appears to be particularly effective for individuals who are initially resistance to change [ 3 , 20 , 23 — 25 ].

Conversely with highly motivated individuals it may be counterproductive[ 26 ]. The tone of MI is nonjudgmental and encouraging.

Counselors establish a non-confrontational and supportive climate in which clients feel comfortable expressing both the positive and negative aspects of their current behavior. Ambivalence is explored prior to moving toward change. Although MI is client-centered, unlike classic Rogerian therapy, it is more goal-driven and directional. That is, there is a clear positive behavioral outcome, e. Given this directionality, some MI practitioners feel it is important to make explicit their "bias" in this regard.

However, to maintain client autonomy they may also explicitly communicate that any decision is ultimately up to client. When MI is used to discuss preference sensitive decisions such as obtaining a genetic test or choosing breast conserving vs. Conversely, in such situations the goal could be conceptualized as making a shared and informed decision, which then could be considered a directional outcome, and still within the rubric of MI.

Whereas many counseling models rely heavily on therapist insight and directive advice, in MI patients themselves do much of the psychological work. They generate the rationale for change. Unlike cognitive-behavioral interventions [ 22 ], MI counselors generally make no direct attempt to dismantle denial or confront irrational or maladaptive beliefs. Instead they may subtly help clients detect possible contradictions in their thoughts and actions; to experience discrepancy between their current actions and who they ideally want to be.

MI counselors rarely attempt to convince or persuade. Instead, the counselor subtly guides the client to think about and verbally express their own reasons for and against change and explore how their current behavior or health status may impact their ability to achieve their life goals or align with their core values. MI encourages clients to make fully informed and deeply contemplated life choices, even if the decision is not to change.

MI arose from intuitive clinical practice rather than any particular theoretical model [ 5 ]. It emerged in part as an alternative to the directive and even confrontational style of substance use counseling commonly used throughout the s[ 5 ]. Many of its principals and techniques are rooted in the client-centered approach of Rogers and Carkauff, although MI is perhaps more goal driven and unidirectional than classic Rogerian client-centered therapy [ 22 , 27 — 29 ]. Despite MI's largely atheoretical origins, in recent years, an increasing number of MI researchers and practitioners have begun to use self-determination theory SDT as a de facto model for understanding how and why MI works [ 30 , 31 ].

Originally proposed by Deci and Ryan [ 30 , 32 , 33 ], SDT conceptualizes a continuum of human motivational regulation [ 34 — 36 ], ranging from amotivated to fully intrinsic, and allows that humans can experience multiple types of motivational regulations simultaneously.

External regulation, one type of controlled regulation, includes extrinsic rewards and punishments administered by other people. It includes, in addition to financial and legal constraints, pressure from other people for the person to change, often in the form of social sanction. Whereas external regulation may temporarily motivate change, such change is seen as less enduring and less stable, particularly if more autonomous forms of self-regulation are low.

Another form of controlled regulation is introjected regulation , whereby a person is motivated not by external controls, but by internalized self-judgment.

Introjections involve some degree of negative self-reference such as shame, guilt, or social comparison, and in this sense they are seen as 'self-controlling'.

Clients often come into counseling with higher levels of those two types of controlled motivation, or being amotivated without intention to change, often feeling unable to change. A key challenge for the MI practitioner is to help the client become more autonomously motivated [ 30 , 31 ], as these forms of self-regulation are associated with long term change see Patrick and Williams in this issue.

Identification is the first type of the more self-determined or autonomous form of regulation. It conveys a sense that change is personally important and meaningful. The most autonomous form of extrinsic motivation is integrated regulation. Here the person not only sees the importance of change, but also links the change with his or her other core values and beliefs. Change arising from integrated regulation is seen as the most stable and enduring.

The person finds meaning in his or her "suffering. They are engaged in for inherent enjoyment rather than any symbolic value. They do not need any symbolic or constructed motivation. This type of motivation, however, is less common as a reason to initiate most behavior change, because most health promoting behaviors are often not perceived as inherently more enjoyable than the riskier behaviors they might be replacing and are perhaps therefore, not intrinsically motivating[ 34 — 36 ].

However, some aspects of positive behavior change, e. SDT also proposes three fundamental human needs that are relevant for motivating behavior change: Competence, relatedness, and autonomy [ 30 , 31 ]. All three needs are consistent with the philosophy and delivery of MI. Competence, akin to the concept of self-efficacy in social cognitive theory [ 37 ], describes people's confidence in their ability to execute change.

Building efficacy for change is a core concept of MI, as reflected by MI practitioners' widespread use by of the 0-to confidence ruler. Competence support can also manifest as "pulling forward" successes from prior behavior change attempts or building a change plan with realistic goals that build efficacy and encourage persistence. Relatedness involves the need for meaningful social connection, which is often integrated into MI through the use of the values clarification activity and through the relationship established with an empathetic, nonjudgmental counselor.

Finally, autonomy in SDT is related to people's need to feel volitional in their actions rather than feeling controlled. Autonomy support is central to the practice of MI[ 30 ].

It is promoted through strategies such as eliciting and acknowledging or reflecting client perspectives and values, shared agenda setting, providing a menu of effective choices for what is discussed and what goals are set, and an overall lack of coercion and direct persuasion throughout the encounter.

MI also promotes autonomous behavior change by linking change to the person's broader goals, values, and sense of self. Measures of controlled and autonomous motivation drawn from SDT have been shown to have a mediating role in MI interventions[ 38 ]. Williams has developed a counseling approach, Autonomy Supportive Therapy, which although directly rooted in SDT shares many MI principles[ 33 , 39 , 40 ]. For more on this, see Patrick and Williams in this issue.

Despite the many similarities between the theory of SDT and the practice of MI, subtle, although potentially important differences have been identified. For example, whereas MI emphasizes the amount, intensity and sequence of change talk as essential elements of the change process[ 5 , 41 ], SDT might place greater emphasis on the quality of the change talk [ 42 ]. Specifically, SDT would hypothesize that integrated and identified change talk should produce more sustained change than talk that has an introjected tone or reflects external pressure, even if such expressions are strong in intensity See also Vansteenkiste et al in this issue.

On the other hand, MI perhaps places greater emphasis on the source of autonomy, that is, effort is placed to ensure that motivation, solutions, and action plans emanate from the client, whereas from an SDT perspective, it may be more important to ensure client volition, even if the initial source of motivation and advice is external i.

In this special circumstance of SDT in medical care, advice delivered in a need supportive manner is predicted to be internalized as autonomous self-regulation over time. Another difference lies in how SDT conceptualizes ambivalence. In MI, clients are often assumed to possess both strong reasons for and against change. Given that the SDT continuum implies motivation is discrete, it is not clear how simultaneous motivations are addressed.

Similarly it is not clear how resistance is conceptualized within SDT. Clients expressing resistance would most likely be viewed as experiencing controlled regulation, either through external pressure or introjected motivation. The goal then, from an SDT perspective would be to help the client find more autonomous reasons for change, which should soften resistance.

In MI however, rolling with resistance is seen as a core strategy for softening resistance. Perhaps SDT might consider such reflections autonomy supportive as they accept the person as they are and do not try to push the person to think differently.

MI has also been linked to complexity science and chaos theory [ 43 , 44 ]. Resnicow et al have suggested that motivation to change one's behavior can be viewed as a perfect storm of intrapsychologic events--a complex, nonlinear interplay of thoughts and feelings that compel the person to change[ 43 , 44 ].

Motivation is not seen as the gradual or intellectual process of decisional balance but a much more discrete event; an epiphany. Such "sudden gains" in motivation have been observed in smoking cessation [ 45 , 46 ] and the treatment of depression [ 47 — 49 ]. To achieve such "quantum change", MI practitioners provide clients with an opportunity to consider their life with and without their risk behaviors and to explore how change can propel them forward in life.

This process can lead to a motivational epiphany, whereby the client feels a compelling reason to change that was not heretofore present[ 43 , 44 ]. The transformation is difficult to predict in part because the system is sensitive to initial conditions, i.

Motivation can be dramatically altered by small inputs. The essence of MI lies in its spirit; however, specific techniques and strategies, when used effectively, help ensure such spirit is evoked.

To this end, MI counselors rely heavily on reflective listening, rolling with resistance, and eliciting change talk. Reflective listening, a core component of client-centered counseling, can be conceptualized as a form of hypothesis testing.

The hypothesis can be stated in generic terms as "If I heard you correctly, this is what I think you are saying Even when reflections are inaccurate, through the act of correcting the counselor, clients may clarify their thoughts and feelings and move the discussion forward.

This is sometimes referred to as a productive miss or a "foul tip. One of the most important elements of mastering MI is suppressing the instinct to respond with questions or premature advice. Questions can be biased by what the counselor may be interested in hearing about, their worldview or prior experience, rather what the client wants or needs to explore. Premature advice, in turn, can elicit resistance or pseudo-commitment. Reflecting helps ensure that the direction of the encounter remains client-driven.

The simplest level of reflection tests whether the counselor understood the content of the client's statement. Deeper levels explore the meaning or feeling behind what was said. Effective deeper-level reflections can be thought of as the next sentence or next paragraph in the story, i. We describe seven types of reflections, the final two, reflections on omission and action reflections, are new variants.

Content reflections are used to elicit the basic facts in the client's story. Although it is perhaps the simplest and least powerful type of reflection, content reflections can be important when trying to gather background information and build initial rapport.

Motivational interviewing MI is a set of communication techniques that can spark behavior change in people with chronic conditions such as diabetes. This style of communication can be a dramatic shift for some providers. Think of MI this way: In usual care, the provider steers the boat, brings the fuel, and charts the course. In MI, the provider is simply the rudder, serving as a guide, and the patient steers. For the first few minutes, just listen and reflect back.

Patients often drop crumbs during the conversation about what they are willing to do. Once a patient has strong motivation and begins brainstorming ways to make behavior changes, a provider can collaborate—respectfully. MI energizes patients to take the lead in managing their condition, in step with their medical providers and supporters. We tell providers to be careful about forced solutions or controlling language. Providers have these great ideas and they want to the fix the person, but we find that prescriptions tend not to fix.

We try to avoid controlling language because it elicits resistance. The literature is quite clear about people who do something because someone made them feel guilty, shamed them, or pressured them. The long-term prognosis for behavior change in such people is poor. Self-management of diabetes, like losing weight or changing lifelong eating habits, can be difficult. Find a way to praise the patient and affirm his or her efforts even if there is little to no success.

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For example, if a client reveals that they started drinking to cope with a partner's infidelity , the counselor might help them reframe the situation. Instead of the client blaming themselves, they may begin to see that the person cheated because of their own issues. Self-efficacy is a person's belief or confidence in their ability to perform a target behavior. A counselor following the motivational interviewing approach supports their client's self-efficacy by reinforcing their power to make the changes they want.

They guide them through the behavior change process, recognize the positive changes clients make, and offer encouragement along the way. In the beginning, the therapist may have more confidence in the individual than they have in themselves, but this can change with ongoing support. Soon, the client starts to recognize their strengths and ability to change their behavior for the better.

In motivational interviewing, counselors help people explore their feelings and find their own motivations. They do this using four basic techniques. Therapists gather information by asking open-ended questions , show support and respect using affirmations , express empathy through reflections , and use summaries to group information.

Open-ended questions are questions you can't answer with a simple "yes" or "no. Such questions often start with words like "how" or "what," and they give your therapist the opportunity to learn more about you. Examples of open-ended questions include:. Affirmations are statements that recognize a person's strengths and acknowledge their positive behaviors. Done right, affirmations can help build a person's confidence in their ability to change. Examples of affirming responses include:.

Reflection or reflective listening is perhaps the most crucial skill therapists use. Reflection lets a client know that their therapist is listening and trying to understand their point of view. It also gives the client the opportunity to correct any misunderstandings and to elaborate on their feelings. Reflection is a foundational skill of motivational interviewing and how therapists express empathy.

Summaries are a special type of reflection. They show that the therapist has been listening and understand what the client has been saying.

Therapists can use summaries throughout a conversation. Some examples of summarizing techniques include:. Originally, motivational interviewing was focused more on treating substance use disorders by preparing people to change addition-related behavior. Over time, however, motivational interviewing has been found to be a useful intervention strategy in addressing other health behaviors and conditions such as:. Motivational interviewing can also be used as a supplement to cognitive behavioral therapy CBT for anxiety disorders, such as generalized anxiety disorder, social anxiety disorder, and post-traumatic stress disorder PTSD.

This approach has even been used to reduce the fear of childbirth. There are several reasons why motivational interviewing is a widely used form of mental health therapy, including:. Motivational interviewing is especially beneficial to people who are initially resistant to starting a treatment program or who are unprepared to make the necessary life changes. Since motivational interviewing was first introduced in the s, studies have shown that it can effectively treat a range of psychological and physical health conditions.

One meta-analysis of 72 clinical trials found that motivational interviewing led to smoking cessation, weight loss, and cholesterol level control. Research also reveals that motivational interviewing can aid in addiction treatment. Another review showed that, of the 39 studies reviewed, two-thirds found that motivational interviewing was associated with significant reductions in adolescent substance use. Yet another review indicates that motivational interviewing can effectively reduce binge drinking as well as the frequency and quantity of alcohol consumed.

Motivational interviewing can effectively treat a variety of conditions. But keep in mind that there is no one form of therapy that is appropriate for everyone and works in every instance. Although motivational interviewing has helped many people find the motivation to make both small and major behavior changes, it's not the ideal course of treatment for everyone.

Motivational interviewing works best for people who have mixed feelings about changing their behavior. If you have absolutely no desire to change your behavior, or are already highly motivated to change, you may not reap the benefits of this approach. If you feel that you or someone you love might benefit from this counseling approach, consider the following first steps:.

Learn the best ways to manage stress and negativity in your life. Miller WR, Rollnick S. Motivational interviewing: Helping people change. Guilford Press; Bandura A. Self-efficacy: Toward a unifying theory of behavioral change. Psychol Rev.