‘‘Social Transformations in Contemporary Society’’, 2013 (1)

ISSN 2345-0126 (online)

MOTIVATIONAL INTERVIEWING: THEORETICAL MODEL AND

WORKING MECHANISM

Raimonda Petroliene

Vytautas Magnus University, Lithuania

Abstract

Purpose – usual counseling methods seeking healthy life are less effective in contemporary
society. Motivational interviewing is declared as one of the best ways for changing unhealthy
behaviors in short time period. The aim of this literature review is to find out how the model of
motivational interviewing is made-up and how it is working in practice.
Design/methodology/approach – literature review about motivational interviewing
theoretical model and working mechanism was made.
Findings – motivational interviewing is a patient centered counseling style which aims to
support individuals to make adjustments in unhealthy behavior by reducing ambivalence and
promoting self-directed changes. It has a number of characteristics which when used flexibly are
crucial to the success of the counseling process. These are the demonstration of empathy, the
development of discrepancy, the ability to roll with resistance and the promotion of self-efficacy.
Motivational interviewing uses a guiding communication style to engage with patients, clarify
their strengths and aspirations, evoke their own motivations for change, and promote autonomy
of decision making. It has been successfully applied with cardiac patients, in particular for those
who need to make lifestyle changes such as diet, exercise, alcohol and medication adherence.
Research limitations/implications – since we didn’t find any motivational interviewing
research in Lithuania a question rises – how this technique works with Lithuanians.
Practical implications – empirical studies should be made on how motivational interviewing
affects Lithuanians.
Originality/Value – motivational interviewing is an innovative counseling method in
Lithuania. Knowledge about it could help patients change their unhealthy behavior.
Keywords: Motivational Interviewing, Theoretical Model, Working Mechanism.
Research type: literature review.

Introduction

Usual counseling methods seeking healthy life are less effective in contemporary
society. People want to change in a relatively short time period. They are willing to see
the real transformation of their unhealthy habits. Motivational interviewing is declared
as one of the best ways for changing unhealthy behaviors in short time period. Despite

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the fact that it is well known technique all over the world, it is quite new for Lithuanians.
The aim of this literature review is to find out how the model of motivational
interviewing is made-up and how it is working in practice.

Design/methodology/approach

Literature review about motivational interviewing theoretical model and working

mechanism was made. The search of scientific literature was made in such data bases as
Ebsco, PubMed, Science Direct. The search of educational literature was made in official
sites of motivational interviewing www.motivationalinterview.org,
www.motivationalinterviewing.org.

Findings

The concept of motivational interviewing evolved from experience in the treatment

of problem drinkers, and was first described by Miller in 1983 (Rollnick, Miller, 1995).
The fundamental concepts and approaches were elaborated by Miller and Rollnick in a
more detailed description of clinical procedures in 1991 (Rollnick, Miller, 1995). These
two documents let to form a clear definition of motivational interviewing (Rollnick,
Miller, 1995): Motivational interviewing is a directive, client-centered counseling style for
eliciting behavior change by helping clients to explore and resolve ambivalence.
Compared with nondirective counseling, it is more focused and goal-directed (Rollnick,
Miller, 1995). The examination and resolution of ambivalence is its central purpose, and
the counselor is intentionally directive in pursuing this goal (Rollnick, Miller, 1995).
Motivational interviewing uses a guiding communication style to engage with patients,
clarify their strengths and aspirations, evoke their own motivations for change, and
promote autonomy of decision making (Rollnick et al., 2010). Main results of this
literature review are presented below according to the questions of the study:
1. How motivational interviewing is described theoretically?
2. How motivational interviewing is working on patients?

Theoretical model

An emergent theory of motivational interviewing on the one hand is proposed,

emphasizing two specific active components: a relational component focused on empathy
and the interpersonal spirit of motivational interviewing, and a technical component
involving the differential evocation and reinforcement of client change talk (Miller, Rose,
2009). On the other hand the theoretical bases of motivational interviewing are outlined,
focusing on self-determination theory (Medley, Powell, 2010).
It is important to distinguish between the spirit of motivational interviewing and
techniques that are recommended to manifest that spirit (Rollnick, Miller, 1995). The
overall spirit of motivational interviewing could be described as client-counselor

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relationship and the therapeutic skill of empathic understanding (Rollnick, Miller,

Butler, 2008; Miller, Rose, 2009):
 Collaborative. Motivational interviewing rests on a cooperative and collaborative
partnership between patient and clinician. There is an active collaborative conversation
and joint decision-making process.
 Evocative. Motivational interviewing seeks to evoke from patients that which they
already have, to activate their own motivation and resources for change. A patient may
not be motivated to do what consultant wants him or her to, but each person has personal
goals, values, aspirations, and dreams.
 Honouring patient autonomy. Motivational interviewing also requires a certain
degree of detachment from outcomes – not an absence of caring, but rather an acceptance
that people can and do make choices about the course of their lives. To recognize and
honor this autonomy is also a key element in facilitating health behaviour change.
The technical hypothesis regarding the efficacy of motivational interviewing states,
that proficient use of the techniques of motivational interviewing will increase clients’ in-
session change talk and decrease sustain talk, which in turn will predict behavior change
(Miller, Rose, 2009). However, it is inappropriate to think of motivational interviewing as
a technique or set of techniques that are applied to or “used on” people (Rollnick, Miller,
1995). It is an interpersonal style, a subtle balance of directive and client-centered
components shaped by a guiding philosophy and understanding of what triggers change,
and if it becomes a trick or a manipulative technique, its essence has been lost (Rollnick,
Miller, 1995; Rollnick, Miller, Butler, 2008). The converging evidence suggests that the
guiding philosophy and principles of motivational interviewing might help to foster
readiness for participation in treatment (Medley, Powell, 2010).
There are three common styles of communication in health care: directing, guiding,
and following (Rollnick, Miller, Butler, 2008). Authors represent these styles as a circle
(Figure 1) where counselor should imagine himself as sitting in the center of a circle, able
to reach out to use the appropriate style as needed (Rollnick, Miller, Butler, 2008). A
skillful practitioner should be able to shift flexibly among these styles as appropriate to
the patient and situation (Rollnick, Miller, Butler, 2008). However, motivational
interviewing is a refined form of guiding style only.

Figure 1. Three communication styles (Rollnick, Miller, Butler, 2008).

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Guiding is well suited to helping people solve behavior-change problems (Rollnick,

Miller, Butler, 2008). A practitioner using motivational interviewing will conduct the
discussion in line with a guiding style, paying particular attention to how to help the
patient make his or her own decisions about behavior change. In contrast to the more
general guiding style, motivational interviewing is specifically goal-directed, pays
particular attention to certain aspects of patient language and involves competence in a
well-defined set of clinical skills and strategies that are used to evoke patient behavior
change (Rollnick, Miller, Butler, 2008).
Motivational interviewing involves enhancing a patient’s motivation to change by
means of four guiding principles (Rollnick, Miller, Butler, 2008; Hall, Gibbie, Lubman,
2012):
1. R: Resist the righting reflex. It is a natural human tendency to resist persuasion.
The patient himself but not counselor should be voicing the arguments for change.
Motivational interviewing is about evoking those arguments from the patient, and that
means first suppressing what may seem like the right to do – the righting reflex.
2. U: Understand the patient’s motivations. It is patient’s own reasons for change,
and not counselor’s that are most likely to trigger behavior change. It means that
counselor have to be interested in the patient’s own concerns, values, and motivations. In
motivational interviewing one proceeds in a way that evokes and explores patients’
perceptions about their current situations and their own motivations for change.
3. L: Listen to the patient. Motivational interviewing involves at least as much
listening as informing. When it comes to behavior change the answers most likely lie
within the patient, and finding them requires some listening.
4. E: Empower the patient. Empowerment is helping patients explore how they can
make a difference in their own health. The patient’s own ideas and resources are key
here. An important role for counselor in this process is to support their hope that such
change is possible and can make a difference in their health. The practitioner is an expert
is facilitating the patients’ bringing their expertise to the consultation.
Motivational interviewing and self-determination theory developed along quite
different pathways, with the former being driven more by practice and induction and the
latter driven more by theory and experimental research (Resnicow, McMaster, 2012).
There could be found pros and cons thinking about self-determination theory as the
theoretical base of motivational interviewing (Deci, Ryan, 2012; Resnicow, McMaster,
2012). Self-determination theory is a macro-theory of human motivation that has been
applied to health-relevant change and is centrally concerned with autonomous self-
regulation comprising both intrinsic motivation and well-internalized extrinsic
motivation (Deci, Ryan, 2012). According to self-determination theory, being autonomous
refers to acting with a sense of volition and the experience of willingness (Deci, Ryan,
2012). Promoting patients’ autonomy or volition is important within motivational
interviewing too (Deci, Ryan, 2012; Resnicow, McMaster, 2012). There is a similar
interpersonal perspective to treating people within motivational interviewing and self-
determination theory, and the intervention techniques used within these two approaches
also have much in common (Deci, Ryan, 2012). Self-determination theory can be viewed
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as a theory that explains the effects that occur when using motivational interviewing
treatments (Markland et al, 2005 in Deci, Ryan, 2012).
Motivational interviewing has been quite congruent with self-determination theory,
as both approaches focus on patients’ taking responsibility for making important health-
related changes (Deci, Ryan, 2012). However, motivational interviewing was developed
within the domain of health-behavior change and paid little attention to theory (Deci,
Ryan, 2012). When Miller and Rose (2009) started to develop a theory for motivational
interviewing its primary focus was on patients’ change talk as the central mechanism for
promoting health-behavior change (Deci, Ryan, 2012). For counselor behaviors and
overall spirit, total positive client change talk was the mediating variable, and has
become an important construct in motivational interviewing (Pirlott et al, 2012). Change
talk means having patients talk about their behaviour change-planning when and how to
do it, enumerating the advantages of doing it, guessing how it might affect the people to
whom they are closest (Deci, Ryan, 2012). Clients are encouraged to express their own
reasons and plans for change using change talk (Resnicow, McMaster, 2012). As Deci and
Ryan (2012) states, this raises some question about the relation of the two approaches,
because autonomy seems recently to have been given less importance in motivational
interviewing than was initially the case. To maintain strong similarity in methods of
motivational interviewing and self-determination theory for promoting health-behavior
change, the discussions of change talk will need to distinguish between autonomous and
controlled change talk and between practitioners being autonomy-supportive rather than
controlled in promoting the change talk (Deci, Ryan, 2012). Authors believe that support
for autonomy is at the heart of person-centered approaches, including motivational
interviewing, and that it should remain there (Deci, Ryan, 2012).
To sum up the theory of motivational interviewing the word “motivational” should
be used only when there is a primary intentional focus on increasing readiness for
change (Rollnick, Miller, 1995). Further, “motivational interviewing” should be used only
when careful attention has been paid to the definition and characteristic spirit described
above (Rollnick, Miller, 1995). It should also be useful to distinguish between
explanations of the mechanisms by which brief interventions work and specific methods,
derived from motivational interviewing, which are designed to encourage behavior
change (Rollnick, Miller, 1995). Although motivational interviewing does, in one sense,
seek to “confront” clients with reality, this method differs substantially from more
aggressive styles of confrontation (Rollnick, Miller, 1995). Motivational interviewing
should not be offered when a therapist behaves as mentioned below, because it violate
the essential spirit of motivational interviewing (Rollnick, Miller, 1995, Rollnick, Miller,
Butler, 2008):
 argues that the person has a problem and needs to change;
 offers direct advice or prescribes solutions to the problem without the person's
permission or without actively encouraging the person to make his or her own choices;
 uses an authoritative/expert stance leaving the client in a passive role;

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 does most of the talking, or functions as a unidirectional information delivery

system;
 imposes a diagnostic label;
 behaves in a punitive or coercive manner.

Working mechanism

Motivational interviewing has been found effective in changing various health

behaviors. Change talk goes beyond the “big four” lifestyle habits: smoking, excessive
drinking, lack of exercise, and unhealthy diet but it also includes the use of aids, devices,
medicines, etc. (Rollnick et al., 2010; Hall, Gibbie, Lubman, 2012). However, it is not a
panacea, not all trials have been positive, and the size of effect has varied widely
(Rollnick, Miller, Butler, 2008). Although empirical investigations strongly support the
use of motivational interviewing, there is no theory to clearly explain how and why
motivational interviewing works (Faris et al, 2009). Researchers are just beginning to
know a little bit about it. Variability in outcomes across and within studies suggests the
need to understand when and how a treatment works and the conditions of delivery that
may affect its efficacy (Miller, Rose, 2009).
It is proposed that motivational interviewing is efficacious because it mobilizes
clients’ inherent resources for motivation, learning, creativity, problem solving, and goal-
driven activity (Faris et al, 2009). It works by activating patient’s own motivation for
change and adherence to treatment that is why patients exposed to motivational
interviewing have been found to be more likely to do positive changes and to follow the
treatment schedule more strictly (Rollnick, Miller, Butler, 2008). This method involves
helping patients to say why and how they might change, and is based on the use of a
guiding style described above (Rollnick, Miller, Butler, 2008). There is something in
human nature that resists being coerced and told what to do, that is why guiding style
reduces patients’ resistance (Rollnick, Miller, Butler, 2008) and suites to consultations
about change (Table 1) (Rollnick et al., 2010).

Table 1. Contrasting directing and guiding styles (Rollnick et al., 2010)

Directing style Guiding style

“OK, so your weight is putting your health at “OK, let’s have a look at this together and see what
serious risk. You already have early diabetes. you think. From my side, losing some weight and
(Patient often resists at this point.) ... getting more exercise will help your diabetes and your
Overweight is conceptually very simple, if you health, but what feels right for you? (Patient often
think about it. Too much in, not enough out. So expresses ambivalence at this point.) ... So you can see
you need to eat less and exercise more. There no the value of these things, but you struggle to see how
way you can get around that simple fact.” you can succeed at this point in time. OK. It’s up to
you to decide when and how to make any changes. I
wonder what sort of small changes might make sense
to you?
Patient replies with a “yes, but ...” argument. Patient says how change might be possible.

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Patients often seem ambivalent or unmotivated, and practitioners typically try to

advise them to change, using a directing style, which in turn generates resistance or
passivity in the patient (Rollnick et al., 2010). Motivational interviewing is an alternative
approach to discussing behavior change that fosters a constructive doctor-patient
relationship and leads to better outcomes for patients (Miller, Rollnick, 2002). There are
mentioned three principles which counselor should follow by applying the motivational
interviewing for patients (Rollnick et al., 2010):
1. engage with and work in collaboration with patients;
2. emphasize their autonomy over decision making;
3. elicit their motivation for change.
It is recommended to use three core communication skills – asking, listening and
informing – in the service of the guiding style to draw out the patients’ ideas and
solutions (Rollnick, Miller, Butler, 2008; Rollnick et al., 2010). This shows that the
psychologist wants to know about and respect their ability to make sound decisions
(Rollnick et al., 2010):
 “Asking” open ended questions – it invites the patient to consider how and why he
might change;
 “Listening” to the patient’s experience – this helps to “capture” patient’s account
with brief summaries or reflective listening, to express empathy, to encourage the patient
to elaborate and is often the best way to respond to resistance;
 “Informing” – it is made by asking permission to provide information and then
asking what the implications might be for the patient.
Motivational interviewing aims to elicit the motivation to change from the patient,
rather than to try to install this in them; it also aims to work with their strengths rather
than just talk about problems and weakness (Rollnick et al., 2010). Rather than impose
psychologist’s priority on patients, there should be conducted an overview by inviting
them to select an issue or behavior that they are most ready and able to tackle (Rollnick
et al., 2010). It is suggested to retain control of the overall direction of the consultation,
and hand over to the patient control about the what, why, and how of change (Rollnick et
al., 2010). Counselor certainly can and should offer his or her views and expertise, but
within a style that is collaborative and emphasizes the patient’s freedom to make any
final decision (Rollnick et al., 2010).
Technical and relational components are not rival or incompatible hypotheses
(Miller, Rose, 2009). Psychotherapy research has long postulated a combination of specific
(technical) and general or non-specific (relational) factors that influence outcome (Miller,
Rose, 2009). Figure 2 illustrates a variety of pathways by which motivational
interviewing may facilitate behavior change (Miller, Rose, 2009):
 consistent practice does significantly increase client change talk and decrease
resistance (pathways 1 and 2);
 the natural language utterances of clients do predict behavior change (pathways 3–
5);

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 there is predicted a direct relationship between therapist style and client outcome
(path 7);
 training clinicians in motivational interviewing should change practice behavior
and improve their clients’ outcomes (pathways 6, 8–10).

Figure 2. Hypothesized Relationships Among Process and Outcome Variables in

Motivational Interviewing (Miller, Rose, 2009)

Motivational interviewing is a psychotherapeutic method that is evidence-based,

relatively brief, specifiable, applicable across a wide variety of problem areas,
complementary to other active treatment methods, and learnable by a broad range of
helping professionals (Miller, Rose, 2009). A testable theory of its mechanisms of action is
emerging, with measurable components that are both relational and technical (Miller,
Rose, 2009).

Conclusions

Although motivational interviewing is introduced as effective and usable method for

health behavior change there is no theory to clearly explain how and why it works.
Evolving theory of this method is emphasizing a relational component focused on
empathy and the interpersonal spirit of motivational interviewing, and a technical
component involving the differential evocation and reinforcement of client change talk.
There is assumption that motivational interviewing is congruent with self-determination
theory because both approaches focus on patients’ taking responsibility for making
important health-related changes. In practice this method is based on the use of a
guiding style. There is proposed that motivational interviewing is working because it
mobilizes clients’ inherent resources for motivation and works by activating patient’s own
motivation for change. According to the fact that there is remaining need to understand
when and how motivational interviewing works and that it is quite an innovative
counseling method in Lithuania empirical studies should be made on how motivational
interviewing affects Lithuanians.

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