Behavioural and Cognitive Psychotherapy, 1995, 23, 325-334
What is Motivational Interviewing?
Stephen Rollnick
University of Wales College of Medicine, Cardiff
William R. Miller
University of New Mexico
Motivational interviewing is a directive, client-centred counselling style
for eliciting behaviour change by helping clients to explore and resolve
ambivalence. It is most centrally defined not by technique but by its
spirit as a facilitative style for interpersonal relationship. This article
seeks to define motivational interviewing and to characterize its essential
nature, differentiating it from other approaches with which it may be
confused. A brief update is also provided regarding (1) evidence for its
efficacy and (2) new problem areas and populations to which it is being
applied.
Introduction
The concept of motivational interviewing evolved from experience in the
treatment of problem drinkers, and was first described by Miller (1983)
in an article published in Behavioural Psychotherapy. These fundamental
concepts and approaches were later elaborated by Miller and Rollnick (1991)
in a more detailed description of clinical procedures. A noteworthy omission
from both of these documents, however, was a clear definition of motivational interviewing.
We thought it timely to describe our own conceptions of the essential
nature of motivational interviewing. Any innovation tends to be diluted
and changed with diffusion (Rogers, 1994). Furthermore, some approaches
being delivered under the name of motivational interviewing (e.g., Kuchipudi, Hobein, Fleckinger and Iber, 1990) bear little resemblance to our
understanding of its essence, and indeed in some cases directly violate what
we regard to be central characteristics. For these reasons, we have prepared
this description of: (1) a definition of motivational interviewing; (2) a terse
account of what we regard to be the essential spirit of the approach; (3)
differentiation of motivational interviewing from related methods with
Reprint requests to William R Miller, Department of Psychology, University of New Mexico,
Albuquerque, New Mexico 87131-1161, USA.
© British Association for Behavioural and Cognitive Psychotherapies
326
S. Rollnkk and W. R. Miller
which it tends to be confused; (4) a brief update on outcome research
evaluating its efficacy; and (5) a discussion of new applications that are
emerging.
Definition
Our best current definition is this: Motivational interviewing is a directive,
client-centred counselling style for eliciting behaviour change by helping
clients to explore and resolve ambivalence. Compared with nondirective
counselling, it is more focused and goal-directed. The examination and
resolution of ambivalence is its central purpose, and the counsellor is intentionally directive in pursuing this goal.
The spirit of motivational interviewing
We believe it is vital to distinguish between the spirit of motivational interviewing and techniques that we have recommended to manifest that spirit.
Clinicians and trainers who become too focused on matters of technique
can lose sight of the spirit and style that are central to this approach. There
are as many variations in technique as there are clinical encounters. The
spirit of the method, however, is more enduring, and can be characterized
in a few key points.
1. Motivation to change is elicited from the client, and not imposed from
without. Other motivational approaches have emphasized coercion, persuasion, constructive confrontation, and the use of external contingencies
(e.g., threatened loss of job or family). Such strategies may have their place
in evoking change, but they are quite different in spirit from motivational
interviewing which relies upon identifying and mobilizing the client's intrinsic values and goals to stimulate behaviour change.
2. It is the client's task, not the counsellor's, to articulate and resolve his
or her ambivalence. Ambivalence takes the form of a conflict between two
courses of action (e.g. indulgence versus restraint), each of which has perceived benefits and costs associated with it. Many clients have never had the
opportunity of expressing the often confusing, contradictory and uniquely
personal elements of this conflict, for example, "If I stop smoking I will
feel better about myself; but I will also put on weight, which will make
me feel unhappy and unattractive". The counsellor's task is to facilitate
expression of both sides of the ambivalence impasse, and guide the client
toward an acceptable resolution that triggers change.
3. Direct persuasion is not an effective method for resolving ambivalence.
It is tempting to try to be "helpful" by persuading the client of the urgency
of the problem and about the benefits of change. It is fairly clear, however,
that these tactics generally increase client resistance and diminish the prob-
What is motivational interviewing? 327
ability of change (Miller, Benefield and Tonigan, 1993; Miller and Rollnick,
1991).
4. The counselling style is generally a quiet and eliciting one. Direct
persuasion, aggressive confrontation, and argumentation are the conceptual
opposite of motivational interviewing and are explicitly proscribed in this
approach. To a counsellor accustomed to confronting and giving advice,
motivational interviewing can appear to be a hopelessly slow and passive
process. The proof is in the outcome (see below). More aggressive strategies,
sometimes guided by a desire to "confront client denial," easily slip into
pushing clients to make changes for which they are not ready.
5. The counsellor is directive in helping the client to examine and resolve
ambivalence. Motivational interviewing involves no training of clients in
behavioural coping skills, although the two approaches are not incompatible.
The operational assumption in motivational interviewing is that ambivalence
or lack of resolve is the principal obstacle to be overcome in triggering
change. Once that has been accomplished, there may or may not be a need
for further intervention such as skill training. The specific strategies of
motivational interviewing are designed to elicit, clarify, and resolve ambivalence in a client-centred and respectful counselling atmosphere.
6. Readiness to change is not a client trait, but a fluctuating product of
interpersonal interaction. The therapist is therefore highly attentive and
responsive to the client's motivational signs. Resistance and "denial" are
seen not as client traits, but as feedback regarding therapist behaviour.
Client resistance is often a signal that the counsellor is assuming greater
readiness to change than is the case, and it is a cue that the therapist needs
to modify motivational strategies.
7. The therapeutic relationship is more like a partnership or companionship
than expert/recipient roles. The therapist respects the client's autonomy and
freedom of choice (and consequences) regarding his or her own behaviour.
Viewed in this way, it is inappropriate to think of motivational interviewing as a technique or set of techniques that are applied to or (worse) "used
on" people. Rather, it is an interpersonal style, not at all restricted to formal
counselling settings. It is a subtle balance of directive and client-centred
components, shaped by a guiding philosophy and understanding of what
triggers change. If it becomes a trick or a manipulative technique, its essence
has been lost (Miller, 1994).
There are, nevertheless, specific and trainable therapist behaviours that
are characteristic of a motivational interviewing style. Foremost among
these are:
• Seeking to understand the person's frame of reference, particularly via
reflective listening
328
S. Rollmck and W. R. Miller
• Expressing acceptance and affirmation
• Eliciting and selectively reinforcing the client's own self motivational
statements—expressions of problem recognition, concern, desire and
intention to change, and ability to change
• Monitoring the client's degree of readiness to change, and ensuring that
resistance is not generated by jumping ahead of the client.
• Affirming the client's freedom of choice and self-direction
The point is that it is the spirit of motivational interviewing that gives rise
to these and other specific strategies, and informs their use. A more complete
description of the clinical style has been provided by Miller and Rollnick
(1991).
Differences from related methods
The check-up
A number of specific intervention methods have been derived from motivational interviewing. The Drinker's Check-up (Miller and Sovereign, 1989;
Schippers, Brokken and Otten, 1994) is an assessment-based strategy
developed as a brief-contact intervention with problem drinkers. It involves
a comprehensive assessment of the client's drinking and related behaviours,
followed by systematic feedback to the client of findings. (The check-up
strategy can be and has been adapted to other problem areas as well. The
key is to provide meaningful personal feedback that can be compared with
some normative reference.) Motivational interviewing is the style with which
this feedback is delivered. It is quite possible, however, to offer motivational
interviewing without formal assessment of any kind. It is also possible to
provide assessment feedback without any interpersonal interaction such as
motivational interviewing (e.g., by mail), and there is evidence that even
such feedback can itself trigger behaviour change (Agostinelli, Brown and
Miller, 1995).
Motivational Enhancement Therapy (MET)
MET is a four-session adaptation of the check-up intervention (Miller,
Zweben, DiClemente and Rychtarik, 1992). It was developed specifically as
one of three interventions tested in Project MATCH (1993), a multisite
clinical trial of treatments for alcohol abuse and dependence. Two followup sessions (at weeks 6 and 12) were added to the traditional two-session
check-up format to parallel the 12-week (and 12 session) format of two
more intensive treatments in the trial. Motivational interviewing is the
predominant style used by counsellors throughout MET.
What is motivational interviewing? 329
Brief motivational
interviewing
A menu of concrete strategies formed the basis for "Brief Motivational
Interviewing', which was developed for use in a single session (around 40
minutes) in primary care settings with non-help-seeking excessive drinkers
(Rollnick, Bell and Heather, 1992). We found that it was not immediately
apparent to primary care workers how to apply the generic style of motivational interviewing during brief medical contacts. Therefore Rollnick and
Bell designed this set of quick, concrete techniques meant to manifest the
spirit and practice of motivational interviewing in brief contact settings. An
unresolved issue is whether the spirit of motivational interviewing can be
captured in still briefer encounters of as little as 5-10 minutes. Numerous
attempts to do this are underway, although only one method has been
published to date (Stott, Rollnick, Rees and Pill, in press).
Brief intervention
This raises a fourth common confusion. Brief intervention in general has
been confused with motivational interviewing, helped perhaps by the introduction of more generic terms such as "brief motivational counselling"
(Holder, Longabaugh, Miller and Rubonis, 1991). Such brief interventions,
as focused on drinking, have been offered to two broad client groups: heavy
drinkers in general medical settings who have not asked for help, and helpseeking problem drinkers in specialist settings (Bien, Miller and Tonigan,
1993).
Attempts to understand the generally demonstrated effectiveness of brief
intervention have pointed to common underlying ingredients, one
expression of which is found in the acronym FRAMES originally devised
by Miller and Sanchez (1994). The letters of FRAMES refer to the use of
Feedback, Responsibility for change lying with the individual, Advicegiving, providing a Menu of change options, an Empathic counselling style,
and the enhancement of Self-efficacy (see Bien et al., 1993; Miller and
Rollnick, 1991). Although many of these ingredients are clearly congruent
with a motivational interviewing style, some applications (e.g., of advicegiving) are not (Rollnick, Kinnersley and Stott, 1993). Therefore motivational interviewing ought not be confused with brief interventions in general. We suggest that the word "motivational" be used only when there is
a primary intentional focus on increasing readiness for change. Further,
"motivational interviewing" should be used only when careful attention has
been paid to the definition and characteristic spirit described above. Put
simply, if direct persuasion, appeals to professional authority, and directive
advice-giving are part of the (brief) intervention, a description of the
330
S. Rollnick and W. R. Miller
approach as "motivational interviewing" is inappropriate. We are concerned
to prevent an ever-widening variety of methods from being erroneously
presented (and tested) as motivational interviewing. It should also be useful
to distinguish between explanations of the mechanisms by which brief
interventions work (which might or might not involve motivational
processes) and specific methods, derived from motivational interviewing,
which are designed to encourage behaviour change.
Differences from more confrontational approaches
Although motivational interviewing does, in one sense, seek to "confront"
clients with reality, this method differs substantially from more aggressive
styles of confrontation. More specifically, we would regard motivational
interviewing as not being offered when a therapist:
• 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
• takes an authoritative/expert stance leaving the client in a passive role
• does most of the talking, or functions as a unidirectional information
delivery system
• imposes a diagnostic label
• behaves in a punitive or coercive manner
Such techniques violate the essential spirit of motivational interviewing.
The efficacy of motivational interviewing
To our knowledge, a motivational interviewing style has been explicitly
tested in only eight completed clinical trials to date, although a number of
others are underway. In the first of these randomised controlled trials,
delivery of the Drinker's Check-up was found to be associated with significant reductions in alcohol use by problem drinkers who sought consultation
(Miller, Sovereign and Krege, 1988). A second study with similar design
(Miller et al., 1993) found a still larger (50%) reduction in alcohol consumption. Two other New Mexico studies evaluated the impact of a single
motivational interview upon alcoholics entering outpatient (Bien, Miller and
Boroughs, 1993) or inpatient treatment (Brown and Miller, 1993). In both
studies, clients randomly assigned to receive a preparatory motivational
interview showed substantially better outcomes at 3-month follow-up.
Handmaker (1993) found that motivational interviewing reduced alcohol
use among pregnant women, but only for the heaviest drinkers. In a medical
setting study, Rollnick et al. (1992) examined the relative effectiveness of
What is motivational interviewing* 331
brief motivational interviewing versus a skills-based intervention for non
help-seeking excessive drinkers who differed in their degree of readiness to
change. Preliminary analyses indicate that motivational interviewing was
superior to skill training for problem drinkers who were relatively less
ready to change, whereas both approaches yielded comparable outcomes
among more motivated patients. Senft and his colleagues (1995) tested a
15-minute motivational interview with problem drinkers identified in primary health care clinics, and found significantly reduced drinking at
6-month follow-up, relative to a randomised control group. In the last
of these trials, Project MATCH (1993), 1,726 treatment-seeking problem
drinkers were randomly assigned to a four-session Motivational Enhancement Therapy (Miller et al., 1992), or to one of two 12-session therapies:
Twelve-Step Facilitation Therapy, or Cognitive-Behavioural Skills Training.
Though completed, the trial's results have not yet been announced.
Taken together, these controlled trials provide reasonable support for
the potential efficacy of motivational interviewing in triggering behaviour
change, at least among problem drinkers. Exactly what elements of motivational interviewing are effective remains to be examined. Miller et al. (1993)
found that therapist confrontiveness was associated with client resistance
and a lack of long-term behaviour change. Contrary to expectations, however, the number of "self-motivational statements" made by clients was not
significantly predictive of behaviour change. This suggests that in order to
trigger change, eliciting positive statements from the client may be less
important than not eliciting resistance. Said another way, the key may be
to comport oneself as a therapist in such a manner as to evoke minimal
resistance. There is a clear need for further unpackaging and testing of key
components of motivational interviewing.
Other applications
Another avenue for exploration is the extension of this method to new
problem areas and populations. Ambivalence about behaviour change is not
a conflict unique to alcohol and other drug problems. In fact, the challenge
of dealing with "unmotivated" clients is a relatively common concern of
clinicians. It is perhaps not surprising therefore that attempts have been
made in recent years to apply motivational interviewing to other problems
including diabetes (Stott et al., in press) pain management (Jensen, in press),
coronary heart disease rehabilitation, compliance with medical advice, eating
disorders, and HIV risk reduction (Baker and Dixon, 1991). Specific adaptations are being developed for youth (Tober, 1991), criminal offenders
(Garland and Dougher, 1991), couples (Zweben, 1991) and concerned family
members, intravenous drug users (Saunders, Wilkinson and Allsop, 1991;
332
S. Rollnick and W. R. Miller
van Bilsen, 1991), smokers, and abusive families. Efforts are also underway
to explore other formats for providing motivational interviewing including
group sessions, brief medical interventions, and computerised or written
self-help materials.
Conclusions
Motivational interviewing represents a promising change-triggering alternative to direct persuasion and aggressive confrontation. Its focus is on exploring and resolving ambivalence, which is a key obstacle to change. It is both
client-centred and directive.
A client-centred spirit is central to the practice of motivational interviewing. Impetus for change is drawn from the client's own intrinsic motives
and goals, and it is the client who gives voice to reasons for change. Direct
persuasion, coercion, and other saliently external controls are avoided. The
therapeutic relationship has a partnership character, and the client's freedom
of choice is emphasized.
The quietly directive side of motivational interviewing is its focus on
exploring and resolving client ambivalence. Clients' self-motivational statements are elicited and strengthened by reflective listening and selective
reinforcement. Early outcome studies have provided support for the efficacy
of interventions based on motivational interviewing, but the underlying
mechanisms of change await clarification.
References
AGOSTINELLI, G., BROWN, J. M. and MILLER, W. R. (1995). Effects of normative
feedback on consumption among heavy drinking college students. Journal of Drug
Education 25, 31-40.
BAKER, A. and DIXON, J. (1991). Motivational interviewing for HIV risk reduction.
In W. R. Miller and S. Rollnick (Eds). Motivational interviewing: preparing people
to change addictive behaviour (pp. 293-302). New York: Guilford Press.
BIEN, T. H., MILLER, W. R. and BOROUGHS, J. M. (1993). Motivational interviewing
with alcohol outpatients. Behavioural and Cognitive Psychotherapy 21, 347-356.
BIEN, T. H., MILLER, W. R. and TONIGAN, J. S. (1993). Brief interventions for alcohol
problems: a review. Addiction 88, 315-336.
BROWN, J. M. and MILLER, W. R. (1993). Impact of motivational interviewing
on participation and outcome in residential alcoholism treatment. Psychology of
Addictive Behaviours 7, 211-218.
GARLAND, R. J. and DOUGHER, M. J. (1991). Motivational intervention in the
treatment of sex offenders. In W. R. Miller and S. Rollnick (Eds). Motivational
interviewing: preparing people to change addictive behaviour (pp. 303-313). New
York: Guilford Press.
What is motivational interviewing?
333
HANDMAKER, N. S. (1993). Motivating pregnant drinkers to abstain: prevention
in prenatal care clinics. Unpublished doctoral dissertation, University of New
Mexico.
HOLDER, H., LONGABAUGH, R., MILLER, W. R. and RUBONIS, A. V. (1991). The cost
effectiveness of treatment for alcoholism: a first approximation. Journal of Studies
on Alcohol 52, 517-540.
JENSEN, M. P. (in press). Enhancing motivation to change in pain treatment. In D.
C. Turk and R. J. Gatchel (Eds). Psychological treatments for pain: a practitioner's
handbook. New York: Guilford Press.
KUCHIPUDI, V., HOBEIN, K., FLECKINGER, A. and IBER, F. L. (1990). Failure of a
2-hour motivational intervention to alter recurrent drinking behaviour in
alcoholics with gastrointestinal disease. Journal of Studies on Alcohol 51, 356-360.
MILLER, W. R. (1983). Motivational interviewing with problem drinkers.
Behavioural Psychotherapy 11, 147-172.
MILLER, W. R. (1994). Motivational interviewing: III. On the ethics of motivational
intervention. Behavioural and Cognitive Psychotherapy 22, 111-123.
MILLER, W. R., BENEFIELD, R. G. and TONIGAN, J. S. (1993). Enhancing motivation
for change in problem drinking: a controlled comparison of two therapist styles.
Journal of Consulting and Clinical Psychology 61, 455^61.
MILLER, W. R. and ROLLNICK, S. (Eds) (1991). Motivational interviewing: preparing
people to change addictive behaviour. New York: Guilford Press.
MILLER, W. R. and SANCHEZ, V. C. (1994). Motivating young adults for treatment
and lifestyle change. In G. Howard (Ed). Issues in alcohol use and misuse by
young adults (pp. 55-82). Notre Dame, IN: University of Notre Dame Press.
MILLER, W. R. and SOVEREIGN, R. G. (1989). The check-up: a model for early
intervention in addictive behaviours. In T. L0berg, W. R. Miller, P. E. Nathan and
G. A. Marlatt (Eds). Addictive behaviours:prevention and early intervention (pp.
219-231). Amsterdam: Swets & Zeitlinger.
MILLER, W. R., SOVEREIGN, R. G. and KREGE, B. (1988). Motivational interviewing
with problem drinkers: II. The Drinker's Check-up as a preventive intervention.
Behavioural Psychotherapy 16, 251-268.
MILLER, W. R., ZWEBEN, A., DICLEMENTE, C. and RYCHTARIK, R. G. (1992). Motiv-
ational Enhancement Therapy manual: a clinical research guide for therapists
treating individuals with alcohol abuse and dependence. (Volume 2, Project
MATCH Monograph Series) Rockville, MD: National Institute on Alcohol Abuse
and Alcoholism.
PROJECT MATCH RESEARCH GROUP (1993). Project MATCH: Rationale and
methods for a multisite clinical trial matching patients to alcoholism treatment.
Alcoholism: Clinical and Experimental Research 17, 1130-1145.
ROGERS, E. M. (1994). Diffusion of innovations (3rd edn). New York: Free Press.
ROLLNICK, S., BELL, A. and HEATHER, N. (1992). Negotiating behaviour change in
medical settings: the development of brief motivational interviewing. Journal of
Mental Health 1, 25-37.
334
S. Rollnick and W. R. Miller
ROLLNICK, S., KINNERSLEY, P. and STOTT, N . (1993). Methods of helping patients
with behaviour change. British Medical Journal 307, 188-190.
SAUNDERS, B., WILKINSON, C. and ALLSOP, S. (1991). Motivational intervention
with heroin users attending a methadone clinic. In W. R. Miller and S. Rollnick
(Eds). Motivational interviewing: preparing people to change addictive behaviour
(pp. 279-292). New York: Guilford Press.
SCHIPPERS, G. M., BROKKEN, L. C. H. M. and OTTEN, J. (1994). Doorlichting
Voorlichting Alcoholgebruik. Nijmegen, The Netherlands: Bureau Beta.
SENFT, R. A., POLEN, M. R., FREEBORN, D. K. and HOLLIS, J. F. (1995). Drinking
patterns and health: a randomised trial of screening and brief intervention in a
primary care setting. Final report to the National Institute on Alcohol Abuse and
Alcoholism (Grant No. AA08976). Portland, OR: Center for Health Research,
Kaiser Permanente.
STOTT, N., ROLLNICK, S., REES, M. and PILL, R. (in press). Innovation in clinical
method: diabetes care and negotiating skills. Family Practice.
TOBER, G. (1991). Motivational interviewing with young people. In W. R. Miller
and S. Rollnick (Eds). Motivational interviewing: preparing people to change
addictive behaviour (pp. 248-259). New York: Guilford Press.
VAN BILSEN, H. P. J. G. (1991). Motivational interviewing: perspectives from the
Netherlands, with particular emphasis on heroin-dependent clients. In W. R.
Miller and S. Rollnick (Eds). Motivational interviewing: preparing people to
change addictive behaviour (pp. 214-224). New York: Guilford Press.
ZWEBEN, A. (1991). Motivational counselling with alcoholic couples. In W. R. Miller
and S. Rollnick (Eds). Motivational interviewing: preparing people to change
addictive behaviour (pp. 225-235). New York: Guilford Press.