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Let the client do it; Motivational Interviewing

Ambika Agnihotri


Motivational interviewing in a client-centred counselling technique used by therapists, for patients who need to overcome ambivalence. It aims to help patients with behavioural change. Since its conception by Bill Miller, it has been studied and opted by numerous psychologists and therapists. The novel style of counselling and the flexibility offered, made this technique popular and has since been used along with various other therapeutic approaches. Through this post, I aim to throw some light upon this technique and briefly explain the process it entails.
Bill Miller, in 1983, was treating patients with drinking problems. He began thinking about the efficiency of behaviour change. Through this experience, he formed the fundamentals of motivational interviewing. In 1991, Miller and Rollnick elaborated on these fundamentals to give this counselling style some shape and structure (Rollnick & Miller, 1995). It grew into a focused, directive and client-centred style for bringing about the required behavioural change, by helping clients gain knowledge about the conflict and eventually resolve ambivalence.
Ambivalence manifests as a conflict between two desired and/or undesired courses of action. There could be numerous reasons for its occurrence; addiction, peer pressure, coercion, etc. While talking about the process of motivational interviewing, it would be better to start by describing the core features or characteristics and then moving on to the process. First and foremost, it is important to note that it is based on an interpersonal style of counselling and isn’t bound by formal counselling settings wherein therapy is ‘applied to’ the patient (Rollnick & Miller, 1995). Finding a balance between directive and client-centred aspects of counselling is extremely important. This technique lies totally opposite to styles like confrontation, aggressive argumentation and directive persuasion. 
The next most important component of motivational interviewing is the therapist-client relationship. It has a huge impact on how the results of counselling turn out. The ideal relationship is like a partnership or a collaboration, where the therapist acts like a facilitator. This may sound easy but is, in fact, difficult to achieve because of what Treasure calls the ‘righting reflex’ (2004). It is the tendency that therapists have, to try and solve the problem for the client. However, in motivational interviewing, the ideal approach is to allow the patient to recognize and understand his/her ambivalence, and subsequently work towards resolving it; it is seen as the patient’s task (Rollnick & Miller, 1995). If the relationship lacks warmth and empathy, and in the presence of direct persuasion from the therapist’s side, the client will be unable to recognise and accept the conflict. Moreover, it might even increase client resistance, which will in turn decrease the probability of realization of the goal. Thus, the therapist adopts a subordinate position to emphasise the patient’s autonomy and the right to choose the level of indulgence (Treasure, 2004).
Moving on to the techniques that are adopted in motivational interviewing, the aim is two-fold: (1) to increase the importance of change in the client’s mind, (2) to increase the client’s confidence regarding realisation of the goal, i.e. ‘change can actually happen’. For the former, the process of developing discrepancy is of utmost importance. Differentiation has to be created between the patient’s values and their current behaviour, that may be contradictory to them. This may be followed by negotiation through which the client thinks about the costs and benefits involved in the process of change. The therapist might help reach the decision of change through selective reinforcement. For improving the client’s confidence, developing his/her self-efficacy is important. The therapist’s role here is to support the client’s autonomy, allow self-reflection, offer positive feedback and encourage small steps (Treasure, 2004).
 The client’s readiness to change is seen as a product of the interpersonal interaction, rather than his/her own trait (Rollnick & Miller, 1995). Thus, the therapist, through active listening, pays attention to the client’s motivational signs. The level of denial or resistance and the rate of self-elicited motivational statements by the client are seen as predictors of change, drawing from the therapist’s behaviour and efficiency. These serve as a feedback to the client-therapist relationship. It has been pointed out that the motivational style of counselling is a balanced combination of three kinds of interactions; following, directing and guiding (Rollnick, Miller, Butler & Aloia, 2008).
Motivational interviewing is the counselling technique that helps the client realise his/her intrinsic need for change. It has proven to be highly effective and has many applications within psychiatry (Treasure, 2004). There have been studies indicating that motivational interviewing proves to be superior than other skill-based interventions, as it was better able to increase readiness to change (Rollnick & Miller, 1995). It has the potential and flexibility of being incorporated into everyday clinical practice (Rollnick, Miller, Butler & Aloia, 2008). It can be adapted to a wide range of clients. An overall treatment regime might include motivational interviewing, followed by other techniques like cognitive-behavioural therapy. It proves to be important and impactful with patients as they shift from being apprehensive about change to being open to it. Thereafter, they can be taken through other required therapies.


References

Rollnick, S., & Miller, W. R. (1995). What is motivational interviewing? Behavioural and cognitive Psychotherapy, 23(4), 325-334. https://doi.org/10.1017/S135246580001643X

Rollnick, S., Miller, W. R., Butler, C. C., & Aloia, M. S. (2008). Motivational interviewing in health care: helping patients change behavior. https://doi.org/10.1080/15412550802093108

Treasure, J. (2004). Motivational interviewing. Advances in Psychiatric Treatment, 10(5), 331-337. https://doi.org/10.1192/apt.10.5.331





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